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

We decided that the Plan does not have to pre-approve Monovisc.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation 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 not medically necessary. Our physician reviewer found the enrollee has a history of right knee pain and advanced arthritis. The records do not show evidence of failure of at least three months of treatment with non-drug therapy (such as a home exercise program, education, weight loss, and/or physical therapy). She already had a knee arthroplasty and coverage of viscosupplementation is excluded when total knee arthroplasty has been considered. The Monovisc is therefore not reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve Monovisc.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stereotactic Body Radiation Therapy (SBRT) for the enrollee.

You asked the Plan to pre-approve SBRT. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no current research showing that your type of cancer responds better to the requested type of treatment than the type of treatment we can approve.

The Plan follows Medicare rules. Medicare rules say that SBRT can be covered if the LCD 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 SBRT. Our reviewer says that SBRT is
not medically reasonable and necessary for the enrollee. SBRT is only covered for low to intermediate risk prostate cancer. This patient with Gleason score 9, and metastatic disease does not fulfill that criteria. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SBRT.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve Stereotactic Body Radiation Therapy (SBRT) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 22, 2020.

You asked the Plan to pay for the ambulance services. You say that the ambulance would not transport you to the preferred hospital. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services on November 22, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 18, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was incorrectly billed.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a denosumab injection (J0897) provided on April 7, 2021.
You asked the Plan to waive the coinsurance for an injection. You say that if you were able to order the injection through a pharmacy, then your insurance would have paid part of the drug cost. You also say that you were told the provider had to order the medication from the office and then administer the injection. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.
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 20% coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance for an injection. The allowed amount of the claim is $1,206.60, resulting in a coinsurance obligation of $241.32. The EOC confirms that 20% is the required coinsurance for this service. A denosumab injection falls within the Medicare Part B prescription drugs 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 coinsurance for a denosumab injection (J0897) provided on April 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health around the clock private duty nursing services.

You asked the Plan to pre-approve around the clock private duty nursing services. You say that the requested services are a medical necessity for you. The Plan denied your request. The Plan says criteria for around the clock private duty nursing have not been met.

The Plan must follow Medicare rules. The rules say that Medicare does not cover around the clock private duty nursing services. However, the Plan offers a private duty nursing benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare and Plan rules to determine if the Plan was correct in denying the request to pre-approve around the clock private duty nursing services. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found that, in this case, the documentation doesn't support that you require 24 hours a day, 7 days a week of private duty nursing care. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Your ventilatory status has been stable and there is no documentation that there has been any complications with your feeding tube.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of around the clock private duty nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health around the clock private duty nursing services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on October 24, 2020 to October 26, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on October 24, 2020 to October 26, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for lab work provided by an out-of-network provider on May 18, 2020.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan
denied your request. The Plan says that prior authorization was not 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 has failed to send in the Plan's 2020 Evidence of Coverage. Therefore,
we decided that the Plan has to pay for lab work provided by an out-of-network provider on May 18, 2020.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95938, 95822) provided on June 9, 2020.
You asked the Plan to pay for neuromonitoring services. You say that these services are supported in the records. The Plan denied your request. The Plan says these services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that if a mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity.
We looked at the file and Medicare rules. The services at issue were billed with Mobile Unit POS code 15, but the records show that they were provided in service of another entity. Based on this information, we decided that Medicare rules for coverage of neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95938, 95822) provided on June 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a protective outer surface covering for an approved prosthesis.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a protective outer surface covering is covered when 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have a left below-knee amputation and are approved for a lower extremity prosthesis. The records do not support that you have special needs for protection against unusually harsh environmental situations for which the requested covering is 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 not been met. Therefore, we decided that the Plan does not have to pre-approve a protective outer surface covering for an approved prosthesis.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hizentra.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has common variable immunodeficiency. She has not tried and failed the Plan's required drugs, Gamunex-C or Flebogamma. The records do not show that the required drugs would be contraindicated or less effective; therefore, Hizentra is not reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve Hizentra.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care services provided from February 17, 2021, to February 19, 2021.
You asked the Plan to waive the copayment for the emergency care services. You say that the Plan should waive the copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the emergency care services. The emergency care services fall within the Emergency Care 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 the emergency care services provided from February 17, 2021, to February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110), and a partial lower denture (D5214) provided on September 17, 2020.

You asked the Plan to pay for the dental services. You say that you made a call to cancel the dental rider after September. You say that in November you made a payment for $76 or the rider coverage in September. You also say that you do not have money to pay the bill from the doctor's office now. The Plan denied your request. The Plan says dentures are not covered services. The Plan says that you were not enrolled in the optional supplemental dental rider on the date of service in this case.

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, you were not enrolled in the optional supplemental dental rider. The record shows that you were disenrolled from the optional supplemental dental rider as of August 31, 2020. Additionally, the record shows that the $76 payment that you made was applied the optional supplemental dental rider premium for July and August. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110), and a partial lower denture (D5214) provided on September 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81161, 81238, 81404, 81407, 81408, 81411, 81413, and 81414) provided to the enrollee on November 23, 2020.

You asked the Plan to pay for the laboratory services. You say that the services were necessary. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. The member had cardiovascular risk assessment testing on November 23, 2020. The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.

Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81161, 81238, 81404, 81407, 81408, 81411, 81413, and 81414) provided to the enrollee on November 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care for the shoulder surgery (CPT code(s): 23472 and 23474), for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the surgical or procedure codes provided are not on the Medicare Inpatient Only List. The Plan states the documentation pre-operatively does not meet the threshold for an intensity of services or underlying enrollee hemodynamic instability that could only be managed in an acute inpatient setting. Medical guidelines discuss the reasons for an inpatient admission and the expected length of stay which is based on the evidence based medical literature.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the surgical CPT code is approved, but the inpatient admission requested is denied. Specifically, the surgery codes given has not been or is no longer on the Medicare Inpatient Only List. The enrollee is medically stable. The documentation pre-operatively does not meet the threshold for an intensity of services or underlying member hemodynamic instability that could only be managed in an acute inpatient setting. The record does not show that the admitting physician reasonably expects that the enrollee's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two (2) midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care for the shoulder surgery (CPT code(s): 23472 and 23474), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided to the enrollee on November 18, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the services billed are not the services that were authorized. Maximus overturned the Plans denial because the case file lacked sufficient information to substantiate the denial. The Plan requested a reopen and provided additional information. The Plan provided the claim and the prior authorization detail. The Plan states that this claim for the evaluation and management of an established patient does not match the approved authorization on file. The Plan states they approved CPT 52601 described as Transurethral electrosurgical resection of prostate under authorization #133783946. The provider billed with CPT code 99212.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due to a discrepancy between the service code approved and service code billed. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for outpatient services provided to the enrollee on November 18, 2020.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of care.

The Plan must follow Medicare rules. The rules say that 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your needs can be met at an alternate 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana 15mcg/2ml solution.
You asked the Plan to pre-approve Brovana. You say that the Brovana is medically necessary. The Plan denied your request. The Plan says a trial of Perforomist is required before alternatives can be considered.
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 Brovana. Our reviewer says that Brovana is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drug or any reason why it would be unsafe or ineffective 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 Brovana have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana 15mcg/2ml solution.