Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and vaccine services (90674, G0008) provided on November 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit and vaccine services. You say that you called customer service and were told that you did have a referral for this doctor but were then told that you did not have a referral for the vaccine provided. The Plan denied your request. The Plan says they only cover out-of-network services in limited circumstances. The provided care was not urgent or pre-approved. The Plan also did not provide or say they had a valid referral for this provider.
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. No referral was provided with this case for review. 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 the office visit (99214) and vaccine services (90674, G0008) provided on November 30, 2020 by an out of network (OON) provider.
Your complaint about possible confusion or miscommunication from the Plan 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.
You asked the Plan to pre-approve Synvisc. The Plan denied your request. The Plan says the enrollee has not tried and failed Monovisc and Orthovisc.
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 Synvisc. Our physician reviewer found that the enrollee has osteoarthritis of the knees. The Plan requires a trial of Monovisc and Orthovisc before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the plan's required drugs would likely be less effective, 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 Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections provided by a participating
provider.

You asked the Plan to waive the coinsurance for injections. You say that you do not agree with these charges.
You say that you would like the Plan to pay this. The Plan denied your request. The Plan says the correct
coinsurance has been 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 a 20%
coinsurance for Medicare Part B prescription drugs.

You have been asked to pay less than a 20% coinsurance of the allowed amount for injections due to reaching
your out-of-pocket maximum. The total allowed amount is $18,674. Your 20% coinsurance is $3,734.80
($18,674 x 20% = $3,734.80). The total amount you are being asked to pay is $3,100. Injections falls within the
Medicare Part B prescription drugs 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
injections provided by a participating provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services for the enrollee.

You asked the Plan to pre-approve the aide services. You say that this is medically necessary. The Plan denied your request. The Plan says the request does not meet the criteria for medical necessity.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 pre-approve the aide services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there is no documentation of home health nursing services or home health therapy services. As such, associated home health aide services are not coverable.

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 aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve combination therapy with Aloxi, famotidine, and heparin flush for the enrollee.
You asked the Plan to pre-approve combination therapy with Aloxi, famotidine, and heparin flush. You say that requested combination therapy is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not med. Maximus overturned the Plans denial. The Plan requested a reopen stating that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. Our Medical Director says that at issue is coverage for combination therapy with Aloxi, famotidine, and heparin flush. The Maximus Physician Reviewer determined that heparin lock flush solution is a standard of care and FDA approved for maintaining patency of IV devices. The Plan states the request was for combination therapy with Aloxi, famotidine, and heparin flush, with the Aloxi component being the basis of the Plan's uphold. The medical records show the enrollee is a 74-year-old woman with a diagnosis of adenocarcinoma of the colon, metastatic to the lung and liver. The enrollee was receiving palliative Folfox plus Mvasi from Aprila of 2020 until October of 2020. Since October of 2020, the enrollee has been receiving single agent "5 FU". Our Medical Director has concluded that the Plan is correct in this case. The correct drug combination regimen was not reviewed. The enrollee is receiving single agent "5 FU (Fluorouracil)", which is a chemotherapeutic agent with low (10% to 30%) emetogenic potential. The documentation does not support that combination therapy with Aloxi, famotidine, and heparin flush was medically reasonable and necessary for the enrollee in this case. Medicare coverage criteria were 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 combination therapy with Aloxi, famotidine, and heparin flush have not been met. Therefore, we decided that the Plan does not have to pre-approve combination therapy with Aloxi, famotidine, and heparin flush for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the chemotherapy drugs (claim lines 13-18) and the CT scan (claim line 10)  provided by the Medical Center on August 17, 2020.

You asked the Plan to waive the cost share for the chemotherapy drugs and the CT scan. You say that you cannot afford the copayment because it is too high. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 20% coinsurance for Medicare-covered Part B Chemotherapy drugs and other Part B drugs and a $200 copayment for all other diagnostic and nuclear medicine radiological services. 

You have been asked to pay $4.15 which is 20% of the allowed amount for the chemotherapy drugs. The allowed amount is $20.70. ($20.70 x 20% = $4.15). You have also been asked to pay a $200 copayment for the CT scan. The chemotherapy drugs fall within the "Medicare Part B prescription drugs" benefit category. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. 
&#8195;
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 cost share for the chemotherapy drugs (claim lines 13-18) and the CT scan (claim line 10) provided by the Medical Center on August 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient hospital services.

You asked the Plan to waive the copayments for the outpatient hospital services. You say that you would like these copayments waived and that you believe you were told a 20% discount would apply. The Plan denied your request. The Plan says you were charged these copayments 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 $325 copayment for surgery or other services provided in an outpatient hospital.

Records show that you had three separate procedures at the hospital. You have been asked to pay a $325 copayment for each of these three outpatient hospital services. The outpatient hospital services fall within the surgery or other services provided in an outpatient hospital 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. Any discounts that you may have negotiated with this facility will need to be addressed with the facility itself. Therefore, we decided that the Plan does not have to waive the copayments for outpatient hospital services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 testing provided on September 24, 2020.
You asked the Plan to pay for the COVID-19 testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no evidence if an established relationship between the member and ordering physician.
The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the COVID-19 testing have not been met. Specifically, there is no evidence that the ordering physician is treating the member. Of note, the ordering physician is located in one state and the member and laboratory are located in a different state. Therefore, we decided that the Plan does not have to pay for the COVID-19 testing provided on September 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient admission for a shoulder arthroplasty.
You asked the Plan to pre-approve acute inpatient hospital admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated as an outpatient.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve for acute inpatient hospital admission. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The arthroplasty procedure is currently approved as an ambulatory outpatient procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital admission have been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient admission for a shoulder arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the orthotics are medically necessary. The Plan
denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sclerotherapy treatments and endovenous ablation for
varicose veins.

You asked the Plan to pre-approve the requested vascular treatments. You say that it is felt this treatment is
necessary. The Plan denied your request. The Plan says there are no functional deficits or severe pain related to
these veins. In addition, no compression therapy has been tried.

The Plan follows Medicare rules. Medicare rules say that treatment of varicose veins may be considered
medically necessary for those who remain symptomatic after a six-week trial of conservative care.

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 requested vascular treatments. Our
reviewer says that the requested vascular surgery is not considered medically reasonable and necessary. Our
physician reviewer found coverage requires that the patient have activity limiting symptoms that are
attributable to the varicose veins being treated despite efforts at conservative treatment. The patient has severe
obesity and has a history of numerous orthopedic implants documented on both sides; however, these issues are
not considered in the evaluation.

These factors suggest her varicose veins may not be the etiology of her symptoms and that she is at elevated
risk for not appreciating meaningful improvement following endovenous ablation. Additionally, the patient
experiences no relief when she elevates her legs and does not appear to be interested in conservative therapy. It
is also unclear what specific treatment is being considered or its relationship to patient's symptoms. As such,
this is not considered a reasonable and necessary 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 requested vascular treatments have not been met. Therefore, we decided that
the Plan does not have to pre-approve sclerotherapy treatments and endovenous ablation for varicose veins.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the anticoagulant management services (93793) provided by an OON provider.

You asked the Plan to pay for the anticoagulant management services. You say that you are part of this Plan's
network and these services should be covered due to medical necessity and the current pandemic. The Plan
denied your request. The Plan says you are not in this Plan's network. The Plan only covers out-of-network
services in limited circumstances. These services were not urgent or pre-approved and no referral was
provided.

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 the anticoagulant management services (93793)
provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says this does not meet the requirements for approval.
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in
general, LTACHs do not provide clinical services that are materially different than those of short term acute
care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The
documentation does not support that the enrollee in this case requires services at the LTACH that are not
available at the acute care hospital where she is currently receiving care. The documentation does not support
that an additional 25 days of acute care hospitalization are reasonably expected for the enrollee in this case.
Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the
diagnosis and condition of the enrollee 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204), lab service (83036) and vaccines (90662, G0009) provided on October 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the medical services. You say that you were not aware that a prior authorization was required for these services. The Plan denied your request. The Plan says they only cover out of network services in limited circumstances. The services provided were not urgent or emergent, nor were they pre-approved. This care could have been provided 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 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 the office visit (99204), lab service (83036) and vaccines (90662, G0009) provided on October 8, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular nerve stimulator for the enrollee.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says acupuncture for stimulation of auricular points is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is not a covered benefit. The requested device is statutorily not covered by Medicare or the plan. Based on this information, we decided that Medicare rules for coverage of the stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular nerve stimulator for the enrollee.