Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) and sleeve (L2397) provided December 26, 2019.You asked the Plan to pay for the orthoses. You say that the records should support the necessity of the service in dispute.The Plan denied your request. The Plan says the records provided do not support the service billed.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 orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in March of 2019, the enrollee was evaluated for knee pain, which was assessed to be due to osteoarthritis. Ten months later, the enrollee received a knee brace. There is no documentation of knee instability or joint laxity. There is no evidence that the enrollee had suffered trauma or undergone surgery, after which he needed joint stabilization. There is no documentation of a plan to even provide this enrollee with a knee brace. The documentation does not support the medical necessity or reasonableness of the service provided. 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 orthoses have not been met.Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833) and sleeve (L2397) provided December 26, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on July 22, 2019 by out of network provider.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request.The Plan says the services rendered are not a covered benefit.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 has network providers available who can provide 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 forthe laboratory services provided on July 22, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit provided on August 27, 2019.
You asked the Plan to pay for office visit. You say that you are appealing with medical records. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.
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 made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit a copy of the applicable Evidence of Coverage (EOC) for this date of service. Without this document, we cannot determine whether this Plan has a network lock-in rule which applies to this service or that the enrollee has been adequately notified of the Plan's benefits and coverage rules. Therefore, the Plan has not shown that its decision to deny payment is correct or justified according to the Plan contract and Medicare rules. Therefore, we decided that the Plan has to pay for an office visit provided on August 27, 2019.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve9 additional skilled nurse and 12 additional physical therapy home health visits.You asked the Plan to pre-approve skilled nurse and physical therapy home health visits. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 skilled nurse and physical therapy home health visits. Our reviewer says that the documentation does not support that the requested home health services are medically reasonable or necessary. Our physician reviewer found the records do not indicate complex wound care, IV antibiotics, new enteral feedings. The records do not show that ongoing skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration beyond what was approved by the health plan. The enrollee should be able to continue to progress with home exercise instruction and additional skilled therapy is not needed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nurse and physical therapy home health visits have not been met.Therefore, we decided that the Plan does not have to pre-approve9 additional skilled nurse and 12 additional physical therapy home health visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services providedon December 27, 2019.You asked the Plan to pay for the nurse practitioner 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 requestedprovider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat 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 nurse practitioner services provided on December 27, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) for the enrollee.You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says the request fora continued stay exceeds the enrollee's medical needs.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve out of network (OON) gastroenterology consultation.
You asked the Plan to pre-approve the OON gastroenterology consult. You say that the enrollee's condition has progressed to the point that you are no longer able to help her. The nearest provider with the expertise in Crohn's disease. The Plan denied your request. The Plan says that the OON provider is not approved since the plan's network has a provider with the necessary expertise to treat the enrollee.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The plan contract says that enrollees must use contract providers. The provider is a non-contract provider. The requested OON provider is approximately 2 hours and 20 minutes away and 146 miles from the enrollee's home. The in-network facility offered by the plan is approximately four hours away and 236 miles away. We find that this network provider is not considered accessible when compared to the OON provider which is one hour 40 minutes or 90 miles closer. Therefore, we decided that the Plan has to pre-approve out of network (OON) gastroenterology consultation.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J0885) for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says Retacrit can be approved.
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 drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found there is no indication
that the enrollee has tried and failed Retacrit. The provided medical records do not indicate that the plan's
required drug would likely be less effective and/or likely have adverse effects 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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Procrit (J0885) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hyperbaric oxygen (HBO) treatment provided on July 10, 2019.
You asked the Plan to waive the copayment for HBO treatment. You say that the provider said that these services were covered at 100%, and if you had known there was a copayment you would not have consented to service. 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 $50 copayment for HBO treatment at an outpatient hospital. You have been asked to pay $50 copayment for HBO treatment. HBO treatment falls within the Outpatient Hospital 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 hyperbaric oxygen (HBO) treatment provided on July 10, 2019.
Your complaint regarding not being told about the cost-share 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory testing coded 80307, 82542, 84228, and G0483 provided on December 23, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory testing. 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.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 has network providers available who can provide 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 forthe laboratory testing coded 80307, 82542, 84228, and G0483 provided on December 23, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the injection of betamethasone acetate provided on September 26, 2019 billed with four units of code J0702.
You asked the Plan to pay for the four units of J0702. You say that this is billed correctly. The Plan denied your request. The Plan says that the documentation does not support the units billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code J0702 is Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg. We find that four units of CPT code J0702 is supported in the medical record. Specifically, the procedure note clearly documents that two cc's of 6mg/cc betamethasone was injected. This means that 12mg of bethamethasone was injected. Since the definition of the billed code is 3mg per unit, four units corresponds correctly to the injection of 2cc's of 6mg/cc betamethasone. Based on this information, we decided that Medicare rules for coverage of the four units of J0702 have been met. Therefore, we decided that the Plan has to pay for the injection of betamethasone acetate provided on September 26, 2019 billed with four units of code J0702.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99310) rendered by the out of network (OON) provider on January 17, 2020.You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the service was provided by an out of network provider, without prior authorization.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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service.Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99310) rendered by the out of network (OON) provider on January 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyewear provided on April 27, 2019.
You asked the Plan to reimburse you for the eyewear. You say that you went to the Provider due to the cost. The Plan denied your request. The Plan says your vision plan does not provide coverage from out-of-network providers.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The Provider is not a network vision provider. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyewear provided on April 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a JACO V2 robotic arm.
You asked the Plan to pre-approve a JACO robotic arm. You say that because of your medical condition you need a JACO robotic arm for safety, self-feeding, hydration, and self-care. The Plan denied your request. The Plan says JACO robotic arms do not primarily serve a medical purpose to help you get better or prevent illness or disease.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a JACO V2 robotic arm.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve cardiac computed tomographic angiography of the heart.
You asked the Plan to pre-approve the cardiac computed tomographic angiography of the heart. You say that the enrollee has been working since January to get scheduled for surgery. You say that the enrollee is now at the point where he cannot wait for the surgery. You say that the enrollee has not had a CT scan in 5 years. The Plan denied your request. The Plan says that the clinical information shows that the same test or one similar to the requested study was previously performed. The plan says that the results of this prior imaging were provided, but did not show why the results were not sufficient for the evaluation of the current clinical condition.
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 the cardiac computed tomographic angiography of the heart. Our reviewer says that the requested cardiac computed tomographic angiography of the heart is medically reasonable and necessary. Our physician reviewer found the enrollee has severe symptomatic aortic valve stenosis with no obstructive coronary disease being considered for TAVR procedure. In this circumstance a CT scan of the chest and heart is standard evaluation to accurately assess left ventricular outflow tract dimensions and to determine exact distance from the aortic valve to the coronary ostia to determine proper size and proper placement of the transcutaneous aortic valve prosthesis. The CT scan is not needed to assess coronary arteries that have already been determined by the coronary angiogram. 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 cardiac computed tomographic angiography of the heart have been met. Therefore, we decided that the Plan has to pre-approve cardiac computed tomographic angiography of the heart.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam.
You asked the Plan to waive the copayment for the eye exams. You say that these were routine eye exams. You say that you thought you would only pay $15. The Plan denied your request. The Plan says the copayments 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 $30 per specialist visit. You have been asked to pay a $30 copayment for each eye exam. The total amount you owe is $60 ($30/exam x 2 exams = $60). The eye exams fall within the "Doctor Visits" benefit category. The records show that medical eye exams were performed. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the eye exam.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is the best option for the enrollee. The Plan denied your request. The Plan says the enrollee has no complex medical needs requiring 24 hour nursing care or frequent physician supervision.
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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 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.