Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan for the enrollee.
You asked the Plan to pre-approve Rituxan. 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 and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Rituxan (Rituximab). The Maximus Physician Reviewer determined that the enrollee has a fairly uncommon condition with limited treatment options. There is some evidence that Rituxan may be beneficial. The reviewer found due to the limited treatment options and the consequences of this condition, this therapy is indicated and reasonable. The health plan has requested a re-opening, citing an error on the face of the evidence. The plan states that the "LCD only covers diagnosis codes of N02.0, N04.0, and N18.6 which do not appear to closely match the member's diagnosis of N05.9 (fibrillary glomerulonephritis)." Our Medical Director says that the medical records show the enrollee is a 66-year-old woman with a diagnosis of fibrillary glomerulonephritis (DNAJB9) with biopsy-proven mild mesangial proliferation and rare segmental glomerulosclerosis. The condition is resulting in massive nephrotic range proteinuria. The enrollee is under the care of a nephrologist. However, in this specific case, Rituxan is not FDA approved for the enrollee's diagnosis. In this particular case, the use of Rituximab for the treatment of fibrillary glomerulonephritis is not supported by one of the major drug compendia, nor by clinical research in a CMS-approved medical journal. Therefore, for this case in particular, 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 Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pre-approve oxygen for treatment of cluster headaches for the enrollee.
You asked the Plan to pre-approve oxygen for treatment of cluster headaches. You say that oxygen is medically necessary for the enrollee. The Plan denied your request. The Plan says the medical records do not show the enrollee in participating in a clinical study. Maximus overturned the Plans denial citing medical necessity. The Plan requested a reopen and stated that medical necessity is not the issue, but that the enrollee does not meet the specific criteria required for coverage by Medicare.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say oxygen equipment prescribed to treat enrollees for cluster headaches is only covered for enrollees participating in a clinical study. The medical records provided do not show the enrollee is participating in a clinical study. While this treatment may be beneficial for the enrollee, it is not a covered treatment by Medicare at this time. Therefore, we decided that the Plan does not have to pre-approve oxygen for treatment of cluster headaches for the enrollee.
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 you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department services (99285) provided on November 9, 2019.
You asked the Plan to pay for the emergency department services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. We asked our coder 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 emergency department services. Our reviewer says that CPT code 99285 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation to meet the CMS requirement of CPT 99285 as described in the coding definition, therefore it is inappropriate to bill 99285 for the service provided on November 9, 2019
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency department services have not been met. Therefore, we decided that the Plan does not have to pay for emergency department services (99285) provided on November 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish, periodontal
maintenance, and two additional intraoral periapical x-rays provided on November 25, 2020.
You asked the Plan to pay for the topical application of fluoride varnish, periodontal maintenance, and
additional intraoral periapical x-rays. You say that you do not feel you should be held responsible for these
charges. The Plan denied your request. The Plan says topical application of fluoride varnish and periodontal
maintenance are not covered. The Plan also says that your benefits for intraoral x-rays had been satisfied and
the frequency limitation had been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, topical application of fluoride varnish
and periodontal maintenance are not among those covered under this benefit. The Plan contract says that
intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first
intraoral periapical x-ray on November 25, 2020, and your intraoral x-rays benefit had been exhausted.
Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish,
periodontal maintenance, and two additional intraoral periapical x-rays provided on November 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.
You asked the Plan to pre-approve Dupixent. You say that the enrollee suffers from severe atopic dermatitis. The Plan denied your request. The Plan says this medication does not fall under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.
Benefits for Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture after a fall. His medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Additionally, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
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 the enrollee needs continued total
parenteral nutrition support. The Plan denied your request. The Plan says the enrollee is no longer in a
medically complex situation.
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 physician
reviewer found that the enrollee was admitted to the acute hospital for sepsis and an abdominal wound. Her
hospital course was complicated due to respiratory failure. here 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 for the 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolastin C for the enrollee.
You asked the Plan to pre-approve Prolastin C. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for severity of deficiency and use of Prolastin-C based on FDA approved-use, compendia sources and policy requirements.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Prolastin C. Our reviewer says that Prolastin C is not medically reasonable and necessary for the enrollee in this case. This patient does not have severe A1AT deficiency. The blood level of A1AT is normal. The phenotype is MZ, with one normal gene. Such patients have a level of A1AT that is sufficient to be protective, so there is no reason to expect benefit from replacement infusions. The accepted standard of care, and expert recommendations, are not to administer supplementation to such patients. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for Prolastin C. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolastin C have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolastin C for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745).

You asked the Plan to pay for the neuromuscular stimulator. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says E0745 was not billed with the required durable medical equipment modifier.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code E0745 is not supported in the record. Specifically, this equipment was not billed with a required durable medical equipment modifier. Based on this information, we decided that Medicare rules for coverage of the neuromuscular stimulator have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator (E0745).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation mileage.
You asked the Plan to provide additional routine transportation mileage. You say that you need a additional miles to get to your appointments. The Plan denied your request. The Plan says this request exceeds your mileage benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when each one-way trip must not exceed 75 miles of driving distance. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide additional routine transportation mileage.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyndamax.
You asked the Plan to pre-approve Vyndamax. The Plan denied your request. The Plan says this medication does not fall under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vyndamax.
Benefits for Vyndamax may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that you are at risk for falling. The Plan denied
your request. The Plan says there are no daily skilled nursing or therapy needs.
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.
Continued SNF services beyond April 15, 2021, were requested. 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 continued services. Our physician reviewer found that you have been in a SNF for back
pain related to a fall, with a prior history of compression fractures. You have been treated with analgesics. You
have been weak and deconditioned. You are at a standby assist level with walking using a wheeled walker. You
are independent with transfers, and independent for activities of daily living. There is no documentation that
you require skilled nursing or therapy services to provide treatment beyond the last covered day. Daily skilled
services are not required on a daily 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 continued services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or at the home with home health care services.
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 SNF care is medically reasonable and necessary for the enrollee. The health plan states that the enrollee does not require SNF services because notes show that the enrollee is able to ambulate 200 feet. These records have not been provided for review. The health plan has failed to prove its argument. The physical therapy and occupational therapy records that have been provided for review, show a patient who is weak and functioning below her reported baseline. A period of skilled services seems medically necessary and reasonable to see if the enrollee can retain her prior level of function. Our physician reviewer found that the enrollee's condition meets Medicare criteria for SNF services. 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of excess skin and breast lift.
You asked the Plan to pre-approve the removal of excess skin and breast lift. You say that you would like reconsideration because the member is pushing to get this service covered. The Plan denied your request. The Plan says this service is cosmetic and not covered.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 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 removal of excess skin and breast lift. Our reviewer says that the documentation is insufficient to establish that the shoulder pain would be alleviated by the requested procedure. There is no documentation of intertrigo. Our reviewer found the requested procedure is considered cosmetic and it is not reasonably expected to improve function. 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 removal of excess skin and breast lift have not been met. Therefore, we decided that the Plan does not have to pre-approve the removal of excess skin and breast lift.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a biopsy provided by a participating
provider on December 11, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with this
copayment. 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 $300
copayment for outpatient surgery/in-network.
You have been asked to pay $185.94 which is less than your copayment amount of $300 for an outpatient
surgery. The correct copayment has been applied to the services that were provided. An outpatient surgery falls
within the outpatient surgery/in-network 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 biopsy provided by a participating provider on December 11, 2020.