Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. 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 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 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician or nursing supervision in an IRF. While the enrollee may benefit and participate in multiple therapies the enrollee's functional level does not require this on an intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea computed tomography (CT) scan of the lower extremity.You asked the Plan to pre-approvea CT scan. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that the documentation does support that the requested CT scan is medically reasonable and necessary. Our physician reviewer found the enrollee's symptom complex presentation includes complaints of bilateral foot and ankle pain with the right side more than the left diagnosed with a mixed picture of Erosive Arthropathy. Physical exam findings severe hallux valgus bilateral possible erosion involving the rightfirst metatarsal head and additional cyst like lucencies involving the mid foot. Mild soft tissue swelling overlaying the left first metatarsophalangeal joint and hammer toes are present. CT scans of the foot are indicated for the evaluation of trauma,sports injuries,falls, fractures, arthritis, osteomyelitis, foreign body and peri-operative assessment and planning. In this case with the multiple abnormalities noted on x-ray a CT scan is indicated. Therefore, the enrollee meets criteria for the requested CT scan.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 CT scan have been met.Therefore, we decided that the Plan has to pre-approvea computedtomography (CT) scan of the lower extremity.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 toopen the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary interim partial denture (D5820) and mandibular interim partial denture (D5821) provided on September 10, 2020.
You asked the Plan to pay for the interim partial dentures. You say that you were not aware that there was no coverage for interim partial dentures. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.
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 pay for the maxillary interim partial denture (D5820) and mandibular interim partial denture (D5821) provided on September 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new power wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation to show that the current power wheelchair is worn beyond repair and that it requires replacement.
The Plan must follow Medicare rules. The rules say that typically, the reasonable useful lifetime of DME is five years. The file shows that the current power wheelchair is less than five years old. Based on this information, we decided that Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a new power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received from September 23, 2019, to May 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the services you received from September 23, 2019, to May 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on October 10, 2020 by an OON provider.
You asked the Plan to pay for the prophylaxis. You say that you feel the Plan should pay the remainder of this bill because you had not used the benefit in full. You also say that you were not aware that this provider was OON. The Plan denied your request. The Plan says your dentist is not in-network with the Plan, and charges more than the allowed amount for the services provided.
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 OON dentist can bill you for additional costs if what they charge is more than the maximum benefit amount for preventive services covered by the Plan. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on October 10, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a medical alert bracelet (E1399).
You asked the Plan to pre-approve this item. You say that a medical alert bracelet is medically necessary. The Plan denied your request. The Plan says a medical alert bracelet is not covered under your contractual policy or by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. While a medical alert bracelet may be appropriate for you in this case, neither the Plan nor Medicare offers coverage of this item. A medical alert bracelet does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a medical alert bracelet (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the external defibrillator (K0606) provided on February 4, 2020. You asked the Plan to pay for the external defibrillator. You say that you would like reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says this DME service K0606 was billed/paid for date of service January 14, 2021, 21 days prior to the denied date of service. The Plan must follow Medicare rules. Medicare rules say that for capped rental items, contractors pay the fee schedule amounts on a monthly rental basis. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the external defibrillator have not been met Specifically, the record indicates that this item was billed and paid 21 days prior to the denied service. Therefore, we decided that the Plan does not have to pay for the external defibrillator (K0606) provided on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 20, 2020 and August 17, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on January 20, 2020 and August 17, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan does not have to waive the cost share applied to the deductible for an office visit surgery provided on June 23, 2020.
You asked the Plan to waive this cost share. You say that the cost of these services should be not applied to the deductible. The Plan denied your request. The Plan says surgical services provided in a physician office are subject to the deductible. Maximus overturned the Plans denial stating the contract was not clear. The Plan requested a reopen and stated that Maximus did not apply the correct contract benefits.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The contract with the Plan says that there is $750 for deductible. The contract also clearly states on page 68 "deductible could apply for additional services performed on the same day in the physician's office." You were provided with outpatient surgery in your physician's office. Outpatient surgery is subject to the deductible. Surgical services in a physician's office are subject to the deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there was a $750 deductible. This cost share is a contractual obligation that had not been met at the time this service was provided. Therefore, we decided that the Plan does not have to waive the cost share applied to the deductible for an office visit surgery provided on June 23, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve radiation therapy (SRS linear-based, stereotactic radiation, physics consult, treatment aids, MLC device for IMRT, dose plan, etc) for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says that there is a lack of medical necessity.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the therapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found given that the treatment of 4+ brain metastases with SRS/SRT in a patient with good performance status is in accordance with accepted standard practice and conforms to national consensus guidelines, it can be assumed that the treatment can be considered 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 the therapy have been met. Therefore, we decided that the Plan has to pre-approve radiation therapy (SRS linear-based, stereotactic radiation, physics consult, treatment aids, MLC device for IMRT, dose plan, etc) for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for orthotics provided on August 28, 2020.
You asked the Plan to pay for the orthotics. You say that the records provided support the items in dispute. The
Plan denied your request. The Plan says that the delivery ticket submitted did not include the carrier's tracking
number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket
submitted. The Plan say that the proof of delivery is not itemized to indicate the specific supplies.
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 forwarded us information that substantiates their decision to deny your request. We found that
both the delivery ticket/packing slip and the proof of delivery have the carrier's tracking number and the
order/invoice number. We found that the packing slip is itemized and indicates the specific supplies delivered.
The Plan's denial reason is not supported by the evidence provided. Therefore, we decided that the Plan has to
pay for orthotics provided on August 28, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient hospital services.You asked the Plan to pre-approveinpatient services. The Plan denied your request. The Plan says there are no significant clinical events requiring inpatient care.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered whenthe 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 inpatient services. Our physician reviewer found that the enrollee presented to the emergency departmentwith report of a recent two falls related to weakness and cognitive decline over the past few months.There was no loss of consciousness or dizziness. His vitals and labs are within normal limits. The enrollee does not have a condition which warrantsinpatient services. He required observation which could takeplace at a lower level of care. The records donot show that the enrolleewould require hospitalization that would cross twomidnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient services have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient hospital services
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest rendered on January 15, 2020.
You asked the Plan to waive the copayment for these services. You say that you thought the services would be covered. The Plan denied your request. The Plan says the copayment was 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 a $155 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility.
Review of the file shows that you received a chest CT on January 15, 2020. Per the contract with the Plan, there is a $155 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $131.35. Given that the allowed amount was less than the $155 copayment, you have been asked to pay $131.35 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest rendered on January 15, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the low dose computed tomography (LDCT) scan provided on September 29, 2020.
You asked the Plan to pay for the CT scan. The Plan denied your request. The Plan says that the scan is covered every 12 months.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. The CT scan at issue in this case was provided by a contract provider. The file does not show that the Plan provided notice that the CT scan would not be covered. Under Medicare rules, this means the CT scan is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the low dose computed tomography (LDCT) scan provided on September 29, 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: Drugs
Decision: Favorable

We decided that the Planhas to pre-approveSandostatin Lar Depot.You asked the Plan to pre-approveSandostatin Lar Depot. You say that you would like reconsideration because very little else exists to help the member's quality of life, hospitalization burden and overall cost of care.The Plan denied your request. The Plan says that for Sandostatin Lar Depot to be covered, the diagnosis of acromegaly carcinoid syndrome or VIP secreting tumor must be indicated.The Plan must follow Medicare rules. The rules say thatMedicare 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 Sandostatin Lar Depot. Our reviewer says that use of Sandostatin Lar Depot in this circumstance has become a medically acceptable alternative by experts in the field and supported by literature especially in situations were other therapy has failed such as with this member. Our physician reviewer found the literature supports that Sandostatin Lar Depot is safe and effective for this indication. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Sandostatin Lar Depothave been met.Therefore, we decided that the Plan has to pre-approveSandostatin Lar Depot.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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean office visit for colonic irrigation.You asked the Planto pre-approvethe visit. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare does not consider colonic irrigation to be medically necessary. Based on this information, we decided that Medicarerules for coverage of the visit have not been met.Therefore, we decided that the Plandoes not haveto pre-approvean office visit for colonic irrigation
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemobile cardiovascular telemetry (93229, 93228).You asked the Plan to pre-approvemobile cardiovascular telemetry. You say that you need this for various issues.The Plan denied your request. The Plan says no documentation to support medical necessity has been received.The Plan must follow Medicare rules. Medicare rules say that Medicare coverage for cardiac telemetry is limited to patients who have demonstrated a specific need for this type of cardiac telemetry service. The ordering physician must have determined and documented that patients who require this service are at low risk for a life-threatening cardiac event.We looked at the file and Medicare rules. Medical records or other documentation demonstrating the need for these services have not been provided. Without this information, it cannot be determined that the criteria for coverage have been met. Based on this information, we decided that Medicare rules for coverage of mobile cardiovascular telemetry have not been met.Therefore, we decided that the Plan does not have to pre-approvemobile cardiovascular telemetry (93229, 93228)