Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan colonography for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that this study is not covered for screening purposes.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee has proven to be very difficult to evaluate for occult colon neoplasm using direct colonoscopy and even barium enema. The best single test remaining for analysis to evaluate for occult colonic neoplasm is thus CT colonography. As she has had multiple previous attempts at conventional screening without success CT colonography as suggested as a 5 year followup is medically reasonable rather than attempting another, likely to be unsuccessful direct colonoscopy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the scan have been met. Therefore, we decided that the Plan has to pre-approve CT scan colonography for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary. The Plan denied your request. The Plan says coverage criteria for a LTACH admission has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 3-wheeled walker.

You asked the Plan to pre-approve a 3-wheeled walker. You say that this item is necessary. The Plan denied
your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.

The file shows that the plan has already approved a walker. This walker serves the same purpose as a 3-
wheeled walker. Therefore, we decided that the Plan does not have to pre-approve a 3-wheeled walker.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Simponi Aria for the enrollee.
You asked the Plan to pre-approve Simponi Aria. You say that this drug is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen stating Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Simponi Aria Solution (golimumab). The Maximus Physician Reviewer determined that while the requested use of Simponi Aria Solution is not FDA-approved for the enrollee's diagnosis, the use is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use was determined to be supported as medically reasonable and necessary. The Plan argues that the use of Simponi Aria for the treatment of hidradenitis suppurativa is not supported by Compendia supported literature. The medical records show the enrollee has a diagnosis of stage 2 Hidradenitis suppurativa. Previous treatments have included Infliximab, Humira, Methotrexate, Nystatin powder, and Zinc oxide paste, in addition to incision and drainage and wide excisions. Our Medical Director has concluded that the Plan is correct in this case. The compendia and the medical literature do not support that the use of Simponi Aria Solution (golimumab) is medically reasonable and necessary for the treatment of hidradenitis suppurativa. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not have to pre-approve Simponi Aria for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care (99220) provided on December 5, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the observation care. You say that you would like reconsideration because the member was seen in the emergency department and then admitted. The Plan denied your request. The Plan says these services were rendered out-of-network, not urgent, emergent or approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider at issue in this case is not a network provider with the Plan. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the observation care. Our reviewer says that based on the provided documentation it appears that the member did not require urgent treatment following initial assessment and treatment in the ED. Our physician reviewer found the observation services would not be considered emergent in nature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the observation care have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pay for the observation care. Therefore, we decided that the Plan
does not have to pay for observation care (99220) provided on December 5, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the office visits provided by an out of network provider.

You asked the Plan to pay for the office visits. You say that the enrollee was admitted to the hospital for
emergency conditions. The Plan denied your request. The Plan says that no prior authorization was obtained.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not attempt to obtain medical records. This means we cannot
determine if the Plan's denial of non-emergent services is supported. Therefore, we decided that the Plan has to
pay for the office visits provided by an out of network provider

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Keytruda (J9271).
You asked the Plan to pre-approve Keytruda. You say that the requested treatment is needed because the enrollee's cancer is spreading. The Plan denied your request. The Plan says continuation of this drug regimen after progression of disease is not supported.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the requested treatment is not medically reasonable and necessary. Our physician reviewer found that the requested use of Keytruda is not FDA-approved for the enrollee's diagnosis because of no prior immunotherapy. The use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Keytruda (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for arterial studies (93923) provided on October 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON arterial studies. You say that authorization is not required for this service. The Plan denied your request. The Plan says OON services require authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for arterial studies (93923) provided on October 27, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing provided on October 20, 2020.
You asked the Plan to pay for the services provided. You say that the test is eligible for payment as long as the service meets the medical necessity guidelines. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. In this case, there are insufficient medical records to show that the ordered testing clearly correlates with the enrollee's given interventions. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder testing provided on October 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder brace (L3960).

You asked the Plan to pay for the shoulder brace. You say that you would like reconsideration because the shoulder brace is medically necessary. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and ordering physician.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the shoulder brace. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal a detailed objective left shoulder physical examination that indicates a need for the requested orthosis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the shoulder brace have not been met. Therefore, we decided that the Plan does not have to pay for a shoulder brace (L3960).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is an 84-year-old male who was hospitalized on March 10, 2021 with acute respiratory failure. The enrollee has completed antibiotic therapy and remains on high flow oxygen. There is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transport (A0428 and A0425).

You asked the Plan to pay for non-emergency transport. You say that you would like reconsideration because
this service is medically necessary. The Plan denied your request. The Plan says ambulance transport to of from
an outpatient office is not a Medicare covered benefit.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for non-emergency transport. Our reviewer says
that the documentation does not support that other means of transport (such as stretcher van, wheelchair van,
taxi, private car, or other type of vehicle) were contraindicated. Our physician reviewer found the
documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining
equipment that only a fully equipped ambulance can provide for safe transport.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of non-emergency transport have not been met. Therefore, we decided that the
Plan does not have to pay for non-emergency transport (A0428 and A0425)
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found based on the medical records provided daily
skilled services are not required beyond April 13, 2021. The enrollee does not require the services on an
inpatient basis, only in a skilled nursing facility setting. Services in the home with home health or in a longterm
care facility on a part time basis appear appropriate in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility care provided from June 23, 2020, to June 24, 2020.
You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the criteria for coverage of the SNF services provided from June 23, 2020, to June 24, 2020.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility care provided from June 23, 2020, to June 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a non-participating provider on November 7, 2020.

You asked the Plan to waive the copayment for an ambulance trip. You say that you do not agree with this being denied. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $265 copayment for ambulance services/emergency ambulance. 

You have been asked to pay a $265 copayment for an ambulance trip. These services were not denied; therefore, the correct copayment has been applied. An ambulance trip falls within the ambulance services/in-network/emergency ambulance benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance trip provided by a non-participating provider on November 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit.

You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because you thought that charges would be waived for COVID-19 testing. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for specialist visits.

You had a specialist visit. Specialist services are not included in the COVID-19 waiver. Therefore, you are responsible to pay the $35 copayment.

You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit.