Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve these services. You say that you would like to get out of the house and go places. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
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 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 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 total hip replacement. Medical conditions are stable. 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. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner for the enrollee.
You asked the Plan to pre-approve the recliner. You say that this is medically necessary. The Plan denied your request. The Plan says only the seat lift mechanism can be approved.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a recliner for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3.
You asked the Plan to pre-approve Gelsyn-3. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet 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 Gelsyn-3. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has pain related to osteoarthritis of the right knee, diagnosis confirmed with imaging studies. The enrollee has failed conservative treatment. The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc. The documentation does not support that there is no indication that the plan's required drug(s) 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve receiver (monitor); external, for use with interstitial continuous glucose monitoring system (CPT code A9278) and sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply (CPT code A9276), for the enrollee.

You asked the Plan to pre-approve the items. You say that the enrollee forgets to take their insulin and monitor their glucose. You state the enrollee has difficulty doing finger sticks multiple times a day and the device will allow for continuous glucose monitoring as well as alerts or hypoglycemic and hyperglycemic events. The Plan denied your request. The Plan says continuous glucose monitors (A9276, A9278) are considered precautionary and therefore, non-covered under the durable medical equipment (DME) benefit.

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 items have not been met. Medicare guidelines say that these items are not covered by Medicare in any payment system. Therefore, we decided that the Plan does not have to pre-approve receiver (monitor); external, for use with interstitial continuous glucose monitoring system (CPT code A9278) and sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply (CPT code A9276), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for a vitrectomy or face down chair provided on February 15, 2021.

You asked the Plan to pay for this equipment. You say that your physician ordered this equipment for your use
at home and it should be covered. The Plan denied your request. The Plan says this equipment is preventative
in nature and is not covered for home use by Medicare.

Maximus overturned the Plans decision stating the chair was recommended by the physician and should be
covered. The Plan requested a reopen and stated that the Evidence of Coverage gives clear notice that durable
medical equipment may require prior authorization. The Plan states that neither you, your physician nor the
DME provider contacted the Plan regarding the use of this equipment, as is required.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules specifically state this
equipment is not covered by Medicare as it is classified as precautionary. You did not follow your Plan
contract rules when obtaining this equipment. Therefore, we decided that the Plan does not have to pay for a
vitrectomy or face down chair provided on February 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on November 10, 2020.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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. We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on November 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 27, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 80053, 82248, 82306,82465, 82533, 82607,82627, 82670, 82728, 82746, 82977, 83036, 83090,83615, 83718, 84144, 84270, 84402, 84403, 84439, 84443, 84478, 84481, 84550, 85025,86141, 87486, 87581, 87798 and 82306 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81;
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 27, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency and observation care provided to the enrollee
from April 11, 2020, to April 14, 2020.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says that outpatient charges cannot be carved out from the inpatient claim.
Maximus overturned the Plans denial stating services provided within 3 days of an inpatient stay are paid. The
Plan requested a reopen and stated that the inpatient admission was not approved, and the claim was denied by
the Plan for payment.
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. This claim cannot be paid
in relation to or result of the inpatient claim as that claim was denied by. Payment for these services will need a
correct claim separate and distinct from inpatient carve out.
Medicare billing criteria are not met. t. Therefore, we decided that the Plan does not have to pay for the
emergency and observation care provided to the enrollee from April 11, 2020, to April 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on March 31, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were advised there would be no charge because you only had an ear cleaning. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $50 copayment for specialist visits.
You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you copayment was applied to the office visit. 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 specialist office visit provided on March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical extractions and deep sedation.
You asked the Plan to pre-approve the surgical extractions and deep sedation. You say that the severity of the extraction will need sedation, and this was denied incorrectly. The Plan denied your request. The Plan says the services are not covered benefits.
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the surgical extractions and deep sedation.
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 an LTACH admission is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to LTACH.
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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bone replacement graft (D7953).
You asked the Plan to pre-approve the bone replacement graft (D7953). You say that tooth #24 needs an extraction and bone graft placed. The Plan denied your request. The Plan says the service is not a covered benefit.
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the bone replacement graft (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultra-lightweight wheelchair and accessories to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an ultra-lightweight wheelchair and accessories to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an ultra-lightweight wheelchair and accessories to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multiple dental extractions to be provided by an out-of-network (OON) oral surgeon.

You asked the Plan to pre-approve the OON dental services. You say that you have medical conditions which make the requested services necessary for your health. Your doctor feels that these services must be provided by an oral surgeon. The Plan denied your request. The Plan says your benefit only covers dental services from network providers. There is a network provider who can render this service.

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, only the services for participating network providers are covered. Therefore, we decided that the Plan does not have to pre-approve multiple dental extractions to be provided by an out-of-network (OON) oral surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 pre-approve genicular nerve radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental/ investigational at this time. There are ongoing clinical trials. The request, therefore, is considered not medically reasonable or 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 genicular nerve radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 use of Euflexxa is considered medically necessary if there is a documented diagnosis of moderate to severe knee osteoarthritis. The magnetic resonance imaging (MRI) of the knee and x-ray of the knee do not show evidence of osteoarthritis. In addition, there are no documented severe signs or symptoms of osteoarthritis. The requested Euflexxa is therefore not considered safe and effective or medically necessary at this time. 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 Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L2275) provided December 16, 2020.

You asked the Plan to pay for the orthosis. You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the documentation does not support the item billed.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery. This item is not detailed on an itemized shipping statement. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for an orthosis (L2275) provided December 16, 2020.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.

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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted with sepsis, acute kidney injury, rhabdomyolysis, and acute cholecystitis. The enrollee continues to have bacteremia and requires intravenous antibiotics and fluids. The record indicates that the enrollee has not received definitive care for his cholecystitis and palliative care is being considered due to poor prognosis. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.

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.