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

We decided that the Plan does not have to waive the copayment for outpatient surgery you had at an outpatient
hospital facility.

You asked the Plan to waive the copayment for the outpatient surgery. You say that you shouldn't have to pay a
copayment since this was a repeat surgery. 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 $345
copayment for surgery services in an outpatient hospital.

You have been asked to pay a $345 copayment for the outpatient surgery. This copayment applies regardless of
the reason for the surgery. 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 outpatient surgery you had
at an outpatient hospital facility.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the optometry office visit provided on March 12, 2019.
You asked the Plan to waive the coinsurance for the optometry office visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says that you received an office visit provided by your primary care doctor on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.
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 does not say in clear and accurate terms how much you should expect to pay for Vision care. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a 20% coinsurance for Vision care. The Plan contract does not clearly say how much enrollees must pay for Vision care. The Plan contract gives a range of 0% to 20% coinsurance. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the coinsurance for the optometry office visit provided on March 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aloxi for the enrollee.

You asked the Plan to pre-approve Aloxi. You say that Aloxi is medically necessary for the enrollee. 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 that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Aloxi (palonosetron). The Maximus Physician Reviewer determined that the enrollee is experiencing nausea and vomiting while receiving weekly Taxol for metastatic breast cancer. Aloxi is indicated given the delayed nature of the chemotherapy induced nausea and vomiting. The Plan argues that Aloxi for the prevention of chemotherapy-induced nausea/vomiting in an enrollee with metastatic breast cancer receiving single-agent paclitaxel (a low emetic risk agent), does not have support in a Medicare-accepted compendia and Medicare-accepted medical journals. The medical records show the enrollee is a 57-year-old woman with a diagnosis of metastatic breast cancer. She is currently receiving IV Taxol (Paclitaxel), 80 mg/m2, on days 1, 8, and 15 of each 28-day cycle. Our Medical Director has concluded the Plan is correct in this case. Aloxi is FDA-approved for the prophylaxis of chemotherapy-induced nausea and vomiting associated with moderately and highly emetogenic chemotherapy. The enrollee is receiving IV Taxol which has low emetogenic potential. 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 Aloxi have not been met. Therefore, we decided that the Plan does not have to pre-approve Aloxi for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on June 20, 2020.You asked the Plan to pay forthe ambulance services. You say that you were treated in place by the medics.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 June 20, 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 forthe ambulance services provided on June 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on April 25, 2020.You asked the Plan to pay forthe ambulance services. You say that you were very dissatisfied with this service and complained to the fire station directly.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 April 25, 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 forthe ambulance services provided on April 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (side guards, folding titanium backrest, titanium frame).

You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The Plan denied your request. The Plan says these are self-help items and comfort features.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items are not medically necessary as the documentation does not support that these items serve a primary medical need. Therefor per Medicare Benefit Policy Manual, Chapter 15, Section 110.1. The side guards, folding titanium backrest, titanium series, outfront glide suspension, extra seat belt are not 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 additional accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (side guards, folding titanium backrest, titanium frame).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702).
You asked the Plan to pre-approve the orthosis. You say that there are several contracted O&P suppliers in the enrollee's area, but there are none trained and certified to supply the MyoPro brace. Therefore, you just supply it directly. The Plan denied your request. The Plan says the requested item is not medically necessary and not covered by Medicare.
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 the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that because Medicare does not have a National Coverage Determination (NCD) or a Local Coverage Determination (LCD) for MyoPro Motion G, the Medical Policy Orthotics/Support Devices was referenced. This policy states: The following is not covered for any line of business: Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated. Also, the Medicare Evidence of Coverage, Chapter 4, Section 3.1 (Exclusions), states: Services considered not reasonable and necessary, according to the standards of Original Medicare are not covered, unless these services are listed by our plan as a covered service. Information reviewed shows MyoPro Motion G is not a covered benefit. The review has determined that the requested Myopro Motion GAssist Device (L8702) is 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 the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay at the in-network benefit level forthe paravertebral facet joint nerve destruction (64636, 64635) rendered by the out of network (OON) provider on October 17, 2019.You asked the Plan to pay at the in-network benefit level forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says your case was not reviewed within the required timeframe and therefore, it was forwarded to the independent review entity. 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for theseservices.Therefore, we decided that the Plan does not have to pay at the in-network benefit level forthe paravertebral facet joint nerve destruction (64636, 64635) rendered by the out of network (OON) provider on October 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy provided an out of network (OON) provider.

You asked the Plan to pay for chemotherapy. You say that you are aware of the authorization policy but you would like this reprocessed and paid due to medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan says that there are in-network providers available for 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 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for chemotherapy provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the foot without contrast for the enrollee.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says symptoms are improving, and MRI should be held off on.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the enrollee has chronic renal disease and long standing left great toe pain. The toe is noted to be red on examination but otherwise no examination abnormality is noted. No laboratory or plain films results are noted. The note assessment indicates symptoms improved and will hold on the MRI. The record does not support the medical necessity and reasonableness of the requested service. Therefore, the requested service cannot be recommended 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the foot without contrast for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion spacer device.

You asked the Plan to pre-approve the device. The Plan denied your request. The Plan says this is an experimental device.

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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that Superion spacer is experimental. More research is needed to show safety and efficacy of the device. Open laminectomy is the gold standard for spinal stenosis treatment.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion spacer device.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a lumbar epidural injection.

You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no indication of a trial and failure of four weeks of non-surgical, non-injection care including physical therapy.

The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 the injections. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you have radicular pain, and have been doing a home exercise program in the past, as well as massage therapy. The request meets the LCD criteria. The request is 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 injections have been met. Therefore, we decided that the Plan has to pre-approve a lumbar epidural injection.

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-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that your doctor advised that you need IRF services. The Plan denied your request. The Plan says this request 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 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Our physician reviewer also found that there is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit.

You asked the Plan to waive the coinsurance for the office visit. You say that you cannot afford this cost sharing. The Plan denied your request. The Plan says you were charged this coinsurance 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 45% coinsurance for out-of-network primary care provider office visits.

You have been asked to pay 45% coinsurance for the office visit. The office visit falls within the out-of-network primary care provider office visits 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 the office visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy drug injections.

You asked the Plan to waive the coinsurance for the drug services. You say that you were not charged for your chemotherapy sessions before, and you do not understand why the charges have only been applied to one drug. You are not sure this bill is correct. The Plan denied your request. The Plan says Medicare Part B drugs require 20% coinsurance, which 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 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay $1,462.54 for the chemotherapy drugs. The Plan's allowed amount for each date of service is $3,656.34 ($3,656.34 x 20% = $731.27 per service date, or $1,462.54 total for two dates of service). According to the explanation of benefits (EOB) provided by the Plan, the charges for the other drugs provided and some of the related services are included in this allowable amount, even though the cost only appears to be applied to one drug. 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 the chemotherapy drug injections.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services with no transportation.

You asked the Plan to pay for ambulance services. You say that you should not be penalized for following the orders of the ambulance staff and COVID-19 protocols that were in place at the time. The Plan denied your request. The Plan says the denial of payment for these services is correct, because ambulance services with no transportation are not covered by Medicare.

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. 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 ambulance services with no transportation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery.

You asked the Plan to waive the copayment for cataract surgery. You say that you received services at an ambulatory surgical center and disagree with the additional $50 copayment. 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 $450 copayment for outpatient surgery, including services provided at hospital outpatient facilities.

The record shows that you received a cataract surgery at an outpatient hospital facility on November 16, 2020. Therefore, you are responsible to pay the $450 copayment.

You have been asked to pay a $450 copayment for cataract surgery. Cataract surgery falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 cataract surgery.