Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve pacemaker placement.
You asked the Plan to pre-approve these services. You say that your heart rate needs to be brought up. The Plan
denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that pacemaker placement is covered when specific
criteria are met.
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 these services. Our reviewer says that
the services are medically necessary. Our physician reviewer found the records show that you have significant
slow heart rate (bradycardia) and were hospitalized for palpitations and fluttering symptoms. A Holter monitor
confirmed that you have baseline sinus bradycardia. Given that you also have noted chest symptoms from this
issue and are not on any rate-lowering medications, the criteria for the pacemaker are met. The services are
reasonable and medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to preapprove pacemaker placement.
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 a clinical trial of Zirabev (bevacizumab).
You asked the Plan to pre-approve a clinical trial of Zirabev. You say that you need a clinical trial of this drug. The Plan denied your request. The Plan says this drug is used for recurrence therapy only not newly diagnosed cancer.
The Plan must follow Medicare rules. Medicare rules say that Medicare approved clinical trials and certain procedures that are part of the clinical trials program can be covered by traditional Medicare, but they are not covered by the health plan. We looked at the file and Medicare rules. Clinical trials are not covered by health plans. You have to work with your physician to register for a clinical trial if one exists. Therefore, we decided that the Plan does not have to pre-approve a clinical trial of Zirabev (bevacizumab).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar
spinal canal and contents (72148).
You asked the Plan to pre-approve a MRI. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not show this is necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 a MRI. Our reviewer says that the
requested MRI is not indicated. Our physician reviewer found routine imaging for low back pain is not
beneficial and may even be harmful, according to new guidelines from the American College of Physicians.
Imaging is indicated only if severe progressive neurologic impairments or signs or symptoms indicating a
serious or specific underlying condition are present, or if the patient is a candidate for invasive interventions.
Immediate imaging is recommended for patients with major risk factors for cancer, spinal infection, cauda
equina syndrome, or severe or progressive neurologic deficits. Imaging after a trial of treatment is
recommended for patients who have minor risk factors for cancer, inflammatory back disease, vertebral
compression fracture, radiculopathy, or symptomatic spinal stenosis. Subsequent imaging should be based on
new symptoms or changes in current symptoms.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a MRI have not been met. Therefore, we decided that the Plan does not have to
pre-approve a magnetic resonance imaging (MRI) of the lumbar spinal canal and contents (72148).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network cost share for medical services to be
provided by an out of network (OON) provider.
You asked the Plan to pre-approve an in-network exception. You say that you are the only occupational
therapist that specialize in low vision enhancement in the enrollee's home. The Plan denied your request. The
Plan says care is available within the plan's network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that if you use an out-of-network provider, your share of the cost for covered services may be higher.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The enrollee does have out-of-network benefits at
a higher cost share. We found no exception that would require the Plan to pre-approve an in-network exception.
Therefore, we decided that the Plan does not have to pre-approve an in-network cost share for medical services
to be provided by an out of network (OON) provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a past medical history of a stroke with left sided weakness, hypertension, asthma and unstable gait who presented to the acute hospital, with a fall and left lower extremity pain and inability to bear weight. She was treated in the hospital non-operatively with analgesics for a non-displaced left inferior pubic ramus fracture. She is weak and unsteady and is working with physical and occupational therapy. She is weight bearing as tolerated and is maximum assist for transfers. She is reported to be medically stable for discharge.

Based on the medical records provided there is no documentation that the enrollee requires skilled nursing services or skilled therapy services on a daily basis. Based on the medical records provided this enrollee does not require the services on an inpatient basis, in a skilled nursing facility 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 admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fordialysis services provided to the enrollee from February 1, 2019 to February 27, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says there is a lack of timely filing.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the services was not filed until March 5, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay fordialysis services provided to the enrollee from February 1, 2019 to February 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on July 23, 2020.
You asked the Plan to pay for the services provided. You say that the glasses did not fit, and you should not be charged so much. The Plan denied your request. The Plan says the claim was processed correctly.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The vision benefit has been applied accordingly and any balance owed is your responsibility. Therefore, we decided that the Plan does not have to further pay for the vision services provided on July 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveSynvisc for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis request does not meet the step therapy criteria.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.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 drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveSynvisc for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveReslizumab.You asked the Plan to pre-approveReslizumab. You say that the enrollee has a long history of uncontrolled asthma.The Plan denied your request. The Plan says there is no literature to support the drug for the enrollee's condition.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 Reslizumab. Our physician reviewer found that you havea history of severe asthma. The requested use of Reslizumab isnot FDA-approved for your diagnosis,as yourrecords do not document an eosinophilic phenotype. There is no support for the drug's use without an eosinophilic phenotype by any of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.The use of Reslizumab is not supported without an eosinophilic phenotype.  There is no documentation that the requested drug is safe and effective and otherwise reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Reslizumab have not been met.Therefore, we decided that the Plan does not have to pre-approveReslizumab.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments foroutpatient mental health services provided from May 4, 2020, to June 5, 2020.You asked the Plan to waive the copayments foroutpatient mental health services. You say that you should only owe a $35 copayment per each visit.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 $40 copayment for each individual visit and a $35 copayment for each group therapy visit for outpatient mental healthcare. The record shows that you received individual outpatient mental health services from May 4, 2020, to June 5, 2020, for a total of 4 visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40 (copayment) x 4 (individual outpatient mental health visits) = $160. You have been asked topay the total copayment amount of $160 for outpatient mental health services. Outpatient mental health services fall within the outpatient mental healthcare 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 copayments foroutpatient mental health services provided from May 4, 2020, to June 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 10, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for the medical services. You say that this was medically necessary and should be
covered. The Plan denied your request. The Plan says this was provided out of network without 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 has network providers
available who can provide 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 the medical services provided on August 10, 2020
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from July 13, 2020, through
August 11, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or
emergent, nor were they approved in advance.
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible
to participate in the Medicare program.
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare
program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from
July 13, 2020, through August 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvetumor treatment field therapy (TTFT).You asked the Planto pre-approvethe TTFT. You say that the National Comprehensive Cancer Network (NCCN) list TTFT with a 2B recommendation for recurrent GBM. You feel that this should be allowed coverage due to a lack of other treatment options.The Plandenied your request. The PlansaysMedicare does not cover this for recurrent disease.The Plan must follow Medicare rules. Medicare rules say that TTFT must be initiated within 7 weeks of the last dose of chemoradiation and is not covered for treatment of recurrent GBM.We looked at the file and Medicare rules. We have found that the enrollee completed chemoradiation in 2018. This is being requested for treatment of recurrent GBM. Based on this information, we decided that Medicare rules for coverage of the TTFT have not been met.Therefore, we decided that the Plandoes not haveto pre-approvetumor treatment field therapy (TTFT).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for outpatient hospital services. You say that these services were medically necessary and equal with treatment standards for the enrollee.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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 has network providers available who can provide 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 the medical services provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation
provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The
enrollee's care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan does not have to pay for practitioner services provided to the enrollee on October 13,
2019.
You asked the Plan to pay for this service. You say that this claim should be covered by the Plan. The Plan
denied your request. The Plan says Medicare billing criteria are not met. Maximus partially overturned the
Plans denial. The Plan requested a reopen and stated that Maximus issued a partial overturn stating that the
Plan should pay for the x-ray (72100) but does not have to pay for the injections (96374, 96375, J1170, and
J1885). It has been determined that on this claim for 72100 defined as a radiologic examination, spine,
lumbosacral; 2 or 3 views denied because the provider billed this service without the appropriate modifier.
Therefore, Medicare billing criteria were not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes and when necessary the required modifiers. In this
case, based on the claim submitted and the medical records, the claim submitted cannot be paid as billed due to
the omission of the required modifier. Medicare rules for coverage of this service have not been met.
Therefore, we decided that the Plan does not have to pay for practitioner services provided to the enrollee on
October 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea complete mandibular denture.You asked the Planto pre-approvethe services. You say that you are not able to eat and you have acid reflux.The Plandenied your request. The Plansaysthe benefit allowance has been met and exhausted.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. The Plan covers dentures once every five years.Dentures were last received on July 13, 2018. Based on this information, we decided that the Plan's rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea complete mandibular denture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for COVID-19 pneumonia. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs.The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee 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-approveacute inpatient rehabilitation facility (IRF) admission and services.