Persius/hicric huggingface dataset:
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower 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.
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for sepsis and left lower extremity cellulitis. The enrollee's medical conditions 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. The patient 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. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for an outpatient surgery provided by a participating provider on November 11, 2020.
You asked the Plan to waive the deductible and copayment for an outpatient surgery. You say that you would like this reprocessed, and you would like the Plan to pay for all of this. The Plan denied your request. The Plan says the correct charges have 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 $1,000 deductible and a $250 copayment for outpatient surgery/in-network. You have been asked to pay a $189.42 deductible and a $250 copayment for an outpatient surgery. The total amount you are being asked to pay is $439.42 ($189.42 + $250 = $439.42). After this claim was processed, you have met your $1,000 deductible; therefore, the correct deductible has been applied. The nerve blocking injection that was provided is considered an outpatient surgery. 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 deductible and copayment for an outpatient surgery provided by a participating provider on November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 additional chiropractic therapy visits.
You asked the Plan to pre-approve the additional therapy visits. You say that the medical records provided will
show proof of medical necessity. The Plan denied your request. The Plan says 7 additional visits are not
medically necessary.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
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 additional therapy visits Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found in this case the enrollee has undergone 27 covered visits. The submitted
documentation does not include sufficient information to establish the medical necessity of continued visits.
The documentation does not include a plan of care as required by the coverage rules. The elements of the
coverage rule 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 additional therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 additional chiropractic therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from September 20, 2019, through September 23, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that the second surgery was a correction of the first surgery. You say that you are contesting the copayment charge. The Plan denied your request. The Plan says the copayment applied 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 $295 per day for days 1-6 of a hospital stay.
You have been asked to pay an $885 copayment for the inpatient stay. ($295/day x 3 days = $885). The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show you were admitted as an inpatient for 3 days. 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 inpatient stay provided from September 20, 2019, through September 23, 2019.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 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 knee pain and a COPD exacerbation. 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, and an intensive rehabilitation therapy program. There is no documented 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. 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 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 for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the psychotherapy provided from January 4, 2021, through February 1, 2021 and the office visit provided by an out-of-network provider on February 2, 2021.
You asked the Plan to waive the cost for the psychotherapy and office visit. You say that you have never paid a copayment before and you cannot afford it now. You say that you only expected to pay $80 a week. The Plan denied your request. The Plan says the copayments for psychotherapy applied correctly and there was no authorization for the out-of-network office visit.
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 Medicare-covered individual or group visit. Your contract with the Plan also 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. You have been asked to pay a $40 copayment for each psychotherapy visit. The psychotherapy falls within the "Outpatient mental health 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 cost for the psychotherapy provided from January 4, 2021, through February 1, 2021.
The provider of the office visit is not a network provider with the Plan. 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 office visit provided by an out-of-network provider on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiac monitoring rendered on January 11, 2021.
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. Medicare rules say that cardiac event detection is covered when specific criteria are met. We looked at the file and Medicare rules. There is no documentation to support that the cardiac monitoring was necessary for the enrollee. 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 pay for the cardiac monitoring rendered on January 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) services coded 72141 and 72146 provided on September 3, 2020.
You asked the Plan to pay for the magnetic resonance imaging (MRI) 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. In this case, the CPT Code Manual definition of code 72141 is magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material. The CPT Code Manual definition of code 72146 is magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material.
We find that CPT codes 72141 and 72146 are not supported in the medical record. Specifically, the submitted medical records do not include the interpretations and report to support that magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material was performed therefore, code 72141 cannot be verified. The submitted medical records do not include the interpretations and report to support that magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material was performed therefore, code 82146 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the magnetic resonance imaging (MRI) services have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) services coded 72141 and 72146 provided on September 3, 2020.
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 stay is medically necessary. The Plan denied your request. The Plan says the stay 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted due to hypoxic respiratory failure from pneumonia. The enrollee remains intubated, and chemically paralyzed and sedated. The enrollee continues to receive acute critical care services that have not been denied. The medical records provided do not indicate that the enrollee requires critical care services that he is not currently receiving that would be available at the LTACH. 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 LTACH services.
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 SNF care. You say that you need SNF care. The Plan denied your request.
The Plan says rules for SNF care have 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 that you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. The patient's rehabilitation and medical needs are currently being met in the IRF facility and can continue to do so until the patient is ready for home or community discharge. 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 admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental implants provided on August 10, 2020.You asked the Plan to pay forthe dental implants. You say that you believe these services should be covered.The Plan denied your request. The Plan says the requested service is not a covered benefit.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, wedecided that the Plan does not have to pay forthe dental implants provided on August 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean exception to the 50 mile limit for routine transportation.You asked the Plan to pre-approveexceptions to supplemental benefits. You say that you require transportation to your eye surgery.The Plan denied your request. The Plan says that the distance for this trip exceeds the 50 mile limit.Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits, they are not required to do so. Medicare does not provide exceptions to supplemental benefits.Therefore, we decided that the Plan does not have to pre-approvean exception to the 50 milelimit for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve behavioral health consultations to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve behavioral health consultations. You say that there are in-network providers available for these services. The Plan denied your request. The Plan says there are in-network providers available to provide these services.
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 behavioral health consultations to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee. You asked the Plan to pre-approve Keytruda. You say that Keytruda 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 Maximus did not apply the correct criteria.Our Medical Director looked at the case file and the reopen request. At issue is coverage for Keytruda. The Maximus Physician Reviewer determined that the requested treatment was medically reasonable and necessary. The Plan argues that the clinical value and effectiveness of Keytruda in the setting of treatment beyond 24 months duration has not been demonstrated in the peer-reviewed literature, and notes that the enrollee is not enrolled in a procedure-specific registry or clinical trial for evidence development. The medical records show the enrollee is a 64-year-old woman with stage IV non-small cell lung cancer. Treatment with Keytruda was initiated on February 4, 2019. Our Medical Direct has concluded that the Plan is correct in this case. The durationor timing of treatment with Keytruda in the setting of non-small cell lung cancer is "until disease progression, unacceptable toxicity, or up to 24 months." There is limited data that shows the potential of treatment with Keytruda beyond 24 months, but at this point the results are preliminary. 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 [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"] have not been met.Therefore, we decided that the Plan does not have to pre-approveKeytruda for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided on October 5, 2020, and October 8, 2020.You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you were not aware that the copayment waiver had ended.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 $30 copayment for outpatient rehabilitation services. You received outpatient rehabilitation services on October 5, 2020, and October 8, 2020. Therefore, you are responsible to pay a $30 copayment per each service. The total amount you owe is: $60. You have been asked to pay the total copayment amount of $60 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services 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 for outpatient rehabilitation services provided on October 5, 2020, and October 8, 2020.