Persius/hicric huggingface dataset:
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 medical records provided support the need for LTACH care. The Plan denied your request. The Plan says the enrollee can receive the services needed at an alternate level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a physical therapy visit provided on February 9, 2021.
You asked the Plan to waive the copayment for physical therapy visit. You say that you paid a $20 copayment at the time of the visit and were told this was all you would owe. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $40 copayment for in-network physical therapy at an outpatient hospital. You have been asked to pay $40 copayment for physical therapy visit. Physical therapy visit falls 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 copayment for a physical therapy visit provided on February 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that records show the enrollee has not completed his full course of care in the hospital.
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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.
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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an otolaryngology (ear, nose, & throat or ENT) office visit provided on March 24, 2021.
You asked the Plan to waive the copayment for ENT visit. You say that you do not want to get charged for a specialist visit when you saw a nurse. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $25 copayment for specialist visit.
You have been asked to pay $25 copayment for ENT visit. ENT visit falls within the Physician/Practitioner
Services, Including Doctor's 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 copayment
for an otolaryngology (ear, nose, & throat or ENT) office visit provided on March 24, 2021.
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 meets admission criteria and his ongoing medical needs warrant a LTACH level of care to achieve a safe and sustainable discharge. The Plan denied your request. The Plan says the enrollee has not completed a full course of care in the hospital.
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 continues to require critical care services due to hypoxia and altered mental status. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
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. The Plan denied your request. The Plan says your needed care is routine.
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 physician reviewer found that you were admitted to the acute care hospital for congestive heart failure, pleural effusion and aortic stenosis. Your medical conditions are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says that this is considered experimental, investigational, and unproven, due to insufficient published evidence to assess the safety and/or impact on health outcomes.
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 device. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has severe heart failure, and is on multiple congestive heart failure (CHF) medications, and a left ventricular assist device with recurrent and recent hospitalization for CHF. Management of his heart failure with standard medical therapy and relying on symptoms and signs has not been effective in keeping him with minimal symptoms and has resulted in acute hospitalizations and recurrent episodes of fluid overload when seen in the outpatient office, requiring multiple diuretic titrations. CardioMEMS pressure device monitoring in this situation can provide additional heart filling pressure data to better manage very complex diuretic and vasodilator regimens. There is also published expert opinion in the cardiology literature as to its appropriate use as well as reasonable patient selection criteria, and FDA approved indications all of which are met in this clinical instance. Given the severe symptoms of recurrent CHF (NYHA Class III), which have necessitated the use of mechanical assist therapy, the complexity of the medical regimen and the failure to prevent acute CHF hospitalization in this enrollee, the use of this device is reasonable and has clinical data, expert opinion, and approved FDA indications to support its use in selected appropriate clinical situations like this one. 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 been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS device 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: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary for your pain and difficulty walking. The Plan denied your request. The Plan says this does not meet the established definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CTC assay provided on February 23, 2021.
You asked the Plan to pay for the CTC assay. 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 pay for the CTC assay. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that this testing is experimental/investigational, and therefore is not medically reasonable and 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 CTC assay have not been met. Therefore, we decided that the Plan does not have to pay for the CTC assay provided on February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 19, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.
Review of the file shows that the Plan uses Local Coverage Determination (LCD) L38294 to support their denial. However, LCD L38294 is not valid for the provider's billing state of Ohio. Therefore, we are unable to use LCD L38294 to substantiate our decision. The laboratory testing at issue in this appeal was requested solely for screening purposes. The documentation does not include documentation to support that the services were not requested solely for screening purposes. In addition, a physician order was not provided in the case file for the services rendered. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the telephone medical discussion with physician (99442) provided January 6, 2021.
You asked the Plan to waive the deductible for the telephone medical discussion with physician. You say that because you never actually received services, the phone call you made with the provider should not be charged. The Plan denied your request. The Plan says the deductible had not yet been met when the services were rendered.
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 a $203 deductible for physician/practitioner services. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible for physician/practitioner services. This cost sharing is a contractual obligation that had not been met at the time the telephone medical discussion with physician was received on January 6, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the telephone medical discussion with physician (99442) provided January 6, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gelsyn-3 injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the step therapy criteria has not been met.
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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has osteoarthritis of the knee. The record indicates that the requested agent is a new start. The enrollee has not tried and failed the plan's preferred step one agents. The prescriber has not stated that the plan's preferred step one agents would not be appropriate 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Gelsyn-3 injection for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for eyelid surgery provided on March 12, 2021.
You asked the Plan to waive the copayment for outpatient surgery. You say that someone at the facility said it would be covered in full with no charge. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $175 copayment for in-network outpatient surgery at an ambulatory surgical center. You have been asked to pay $175 copayment for outpatient surgery. Outpatient 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 eyelid surgery provided on March 12, 2021.
Your complaint regarding not being told about the cost-sharing for this service is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ultrasound, pelvic (nonobstetric), real time with image documentation (76856) provide February 25, 2021.
You asked the Plan to waive the copayment for the diagnostic services. You say that you are being billed an incorrect amount and you would like this investigated. The Plan denied your request. The Plan says this claim was processed with the correct copayment applied per the Evidence of Coverage
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 $110 copayment for Medicare covered diagnostic radiology services. You have been asked to pay $93.03 copayment for the diagnostic service. Since the allowed amount of $93.03 is less than the copayment amount of $110, you are responsible for the lesser amount. The diagnostic service falls within the Outpatient diagnostic tests and therapeutic services and 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 copayment for ultrasound, pelvic (nonobstetric),
real time with image documentation (76856) provide February 25, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the services (99291, 99292, 31500) provided on November 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed services are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our coding 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 the use of code 99291, 99292, and 31500 is supported by the records provided. Our coding reviewer found that the provider clearly documents the deterioration of respiratory status of the patient, as well as, tests and procedures performed during critical care services. Provider also documents time spent with patient and family during critical care services. We looked at this coder'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 has to pay for the services (99291, 99292, 31500) provided on November 3, 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: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve 10mg Rituximab (J9312).
You asked the Plan to pre-approve the Rituximab. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says that there is no reason the Plan's preferred drugs should not be used because they would be harmful for the member.
The Plan must follow Medicare rules. Medicare rules say that if a Plan decides to adopt and apply step therapy to Part B drugs, the plan must disclose that Part B drugs may be subject to step therapy requirements in the Medical Benefits Chart under "Medicare Part B prescription drugs." We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Rituximab have been met. Specifically, the Medicare Part B Prescription Drugs section of the Medicare Benefits Chart does not disclose information regarding step therapy. Therefore, we decided that the Plan has to pre-approve 10mg Rituximab (J9312).
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.