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

We decided that the Plan does not have to pre-approve a SNF admission.
You asked the Plan to pre-approve SNF admission. You say that you cannot take care of the enrollee anymore. The Plan denied your request. The Plan says the enrollee does not require complex daily nursing care.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to ADLs with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF admission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 injections (J7328).
You asked the Plan to pre-approve Gelsyn-3. You say that Gelsyn-3 is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Gelsyn-3. Our reviewer says that Gelsyn-3 is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs, or any reason why the plan preferred drugs would be unsafe or ineffective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3 injections (J7328).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a knee brace (L1833) provided on
December 11, 2020.
You asked the Plan to waive the coinsurance for a knee brace. You say that the same knee brace is under $100
through Amazon. The Plan denied your request. The Plan says the correct coinsurance was 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 20%
coinsurance for Medicare-covered equipment and supplies.
You have been asked to pay $138.01, or 20% of the Medicare-allowed amount of $690.06, for a knee brace. A
knee brace falls within the "Durable medical equipment (DME) and related supplies" benefit category. This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the coinsurance for a knee brace (L1833) provided on December 11, 2020.
Your complaint about the Plan paying more for a knee brace than the price available through non-Medicare online retailers is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Edarbyclor 40-25mg tablet.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this plan does not cover outpatient prescription drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Edarbyclor 40-25mg tablet.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve presbyopia-correcting (P-C) function of the intraocular
lens.
You asked the Plan to pre-approve P-C function of the intraocular lens. The Plan denied your request. The Plan
says this is not medically necessary.
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 P-C function of the intraocular lens.
Our reviewer says that the requested services are not considered medically reasonable and necessary in this
case. Our physician reviewer found that the provided documentation does not indicate a diagnosis of
presbyopia. The medical records do not support the medical necessity or reasonableness of the requested
service. The elements of the coverage criteria are not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of P-C function of the intraocular lens have not been met. Therefore, we decided
that the Plan does not have to pre-approve presbyopia-correcting (P-C) function of the intraocular lens.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the dental services (D0120, D0274, D1110, D2150) received February 2 through February 16, 2021 from an out-of-network provider.
You asked the Plan to pay an additional amount for the dental services. You say that the Plan should fully cover the requested services. The Plan denied your request. The Plan says when you receive services from an out-of-network provider you are responsible for any amount greater than the Plan's maximum allowable fee.
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. The Plan covers the dental services when the services are medically necessary and reasonable.
We looked at the file, and Medicare rules. The Plan agreed to pay up to the maximum allowable fee charged by the out-of-network provider for the requested services. Your contract states that you are responsible for any amount billed by an out-of-network provider above the Plan's maximum allowable fee. Based on this information, we decided that the Plan has provided coverage in accordance with the Plan contract. Therefore, we decided that the Plan does not have to pay an additional amount for the dental services (D0120, D0274, D1110, D2150) received February 2 through February 16, 2021 from an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network provider.
You asked the Plan to pre-approve physical therapy. You say that you were referred to this provider and confirmed they are in-network. You say that you had to cancel therapy because you cannot afford to continue. The Plan denied your request. The Plan says the services would not be covered by your plan because it was requested during a time when your plan was not in effect.
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 had network providers available who could 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 physical therapy to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the cervical spine.

You asked the Plan to pre-approve a cervical CT. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 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 cervical CT. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found that detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. There is no documentation of a recent cervical X-ray having been completed that failed to demonstrate any pathology and/or was non-diagnostic. It is noted that the Plan approved a magnetic resonance imaging (MRI) scan. Documentation does not indicate this has been completed and that the additional requested CT imaging is still needed. There is no evidence of severe and/or progressive neurological abnormalities. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception.

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 cervical CT have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the cervical spine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible applied to chiropractic manipulative treatment provided by an out-of-network (OON) chiropractor on December 9 - December 28, 2020. We also decided that the Plan does not have to pay for the office visit, cervical x-ray, thoracic x-ray and lumbosacral x-ray provided by an OON chiropractor on December 9, 2020.
You asked the Plan to waive the deductible applied to the OON chiropractic manipulative treatment. You also asked the Plan to pay for the office visit and x-rays provided by the OON chiropractor. You say that the OON chiropractor was within the network at one time. You say that, at the time of your care, you did not know he was out of network. You say that you would not have chosen this provider if you knew this information. The Plan denied your request. The Plan says the manipulation services were provided OON, and the cost sharing that was applied is a contractual agreement. The Plan also says that office visits and x-rays are not a Medicare covered benefit when supplied by a chiropractor and that you are responsible for 100% of the cost for these services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $1,500 for out-of-network medical services. The chiropractic manipulative treatment you asked the Plan to waive the deductible applied to falls within the benefit category out-of-network medical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,500 for out-of-network medical services. This cost sharing is a contractual obligation that had not been met at the time the OON chiropractic manipulative treatment was received on December 9, 2020, to December 28, 2020. Therefore, we decided that the Plan does not have to waive the deductible applied to chiropractic manipulative treatment provided by an out-of-network (OON) chiropractor on December 9 - December 28, 2020.
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.
The office visit and x-rays you asked the Plan to pay for are not manual manipulation of the spine and were provided by a chiropractor. Therefore, we decided that the Plan does not have to pay for the office visit and x-rays provided by a chiropractor on December 9, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to waive the copayment for the SNF services provided from December 28, 2020 to December 31, 2020.
You asked the Plan to waive the copayment for the SNF services. You say that you were not attended to properly and you shouldn't have to pay for the services. The Plan denied your request. The Plan says that the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment pr day for days 1-20 and a $178 copayment per day for days 21-100 at an in-network skilled nursing facility. The Plan says you must pay a $178 copayment for each day. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for each day. The records show the SNF services began on December 12, 2020. December 12, 2020 through December 31, 2020 would be considered days 1-20 of the benefit period. The Plan did not show there were previous SNF days in this benefit period to make a copayment apply to these dates of service. Therefore, we decided that the Plan has to waive the copayment for the SNF services provided from December 28, 2020 to December 31, 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: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (Pembrolizumab).
You asked the Plan to pre-approve Keytruda (Pembrolizumab). You say that this drug is medically necessary
for the enrollee's condition. The Plan denied your request. The Plan says this drug regimen is not supported for
the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
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 Keytruda (Pembrolizumab). Our
reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician
reviewer found the requested drug is not FDA-approved for the enrollee's condition.
In addition, there is no compendia basis or literature support for this regimen with Keytruda in adrenal cancer. Therefore, this drug will be considered experimental and investigational for the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda (Pembrolizumab) have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (Pembrolizumab).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for cognitive function therapy services provided to the enrollee
from October 12, 2020 to October 30, 2020.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your
request. The Plan says the Evidence of Coverage clearly states that the plan only covers physical therapy,
occupational therapy, and speech language therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 pay for the services. Our reviewer says that skilled
services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the documentation does not reveal that the enrollee required cognitive
skills training with skilled services to improve, restore, maintain or prevent deterioration during the dates of
service. The enrollee has a history of dementia with evidence of significant cognitive dysfunction. Evidence-based
reviews indicate that cognitive rehabilitation (and specifically memory rehabilitation) is not
recommended for patients with severe cognitive dysfunction. The cognitive therapy techniques used in the
enrollee's therapy did not require separate reporting and were 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 services have not been met. Therefore, we decided that the Plan does not
have to pay for cognitive function therapy services provided to the enrollee from October 12, 2020 to October
30, 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 enrollee requires daily physician rounding, daily lab monitoring, and continued oxygen weaning. The Plan denied your request. The Plan says the enrollee can safely receive care in another setting.
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 physician reviewer found that in this case, the enrollee was admitted with COVID -19 pneumonia. He continues on high flow oxygen and steroids. He is not clinically stable. He continues to receive acute care services that have not been denied. The medical records provided do not indicate that he requires acute care services that he is not currently receiving that would be available at the LTACH. Therefore, the requested services are 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar orthosis provided on November 28, 2020.
You asked the Plan to pay for the orthosis. You say that the services were necessary to treat the enrollee's condition. The Plan denied your request. The Plan says the reasonableness of the provided equipment has not been established.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. 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 pay for the lumbar orthosis provided on November 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox for the enrollee.
You asked the Plan to pre-approve Botox. You say that Botox is medically necessary. The Plan denied your request. The Plan says the required step therapy showing trial and failure of Xeomin were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information regarding their step therapy requirement.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Botox. The medical records show the enrollee is an 85-year-old man with blepharospasm. The Plan requires a trial of the drug Xeomin before they will approve Botox. The documentation in the medical record\ does not support that treatment with Xeomin has been tried and failed. In addition, the documentation does not support that Xeomin would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the required step therapy 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 Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the services provided by an out-of-network provider on August 7, 2020.