Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on January 11, 2021.

You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.

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 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 outpatient services provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve block injections.
You asked the Plan to pre-approve genicular nerve block injections. You say that this request is medically necessary. The Plan denied your request. The Plan says the coverage criteria have not been met.
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 genicular nerve block injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is the subject of ongoing clinical trials to determine its role in the management of osteoarthritis of the knee. Therefore, the request is deemed 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 genicular nerve block injections have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve block injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection (G0463, 20610, J1040) provided March 15, 2021.
You asked the Plan to waive the copayment for the injection. You say that the injection was provided in a doctors office and the copayment should be waived. The Plan denied your request. The Plan says the claim shows the service was an outpatient surgical procedure and the correct copayment 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 a $250 copayment for outpatient procedures. You have been asked to pay a $250 copayment for the injection. the injection falls within the outpatient procedures 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 injection (G0463, 20610, J1040) provided March 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the thermal capsulorrhaphy rendered on February 23, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for left
shoulder adhesive capsulitis and subacromial bursitis with bony impingement.

The requested thermal capsulorrhaphy is considered experimental/investigational in nature and is therefore not
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not
have to pay for the thermal capsulorrhaphy rendered on February 23, 2021.

Local Coverage Article (LCA) A53435 referenced by the Plan is not valid for the state of Florida and was not
used in the MAXIMUS determination.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick. 
 
You asked the Plan to pre-approve Repatha Sureclick. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee has a medical only policy which does not include Part D 
prescription coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Repatha Sureclick.  
 
Benefits for Repatha Sureclick may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve homecare skilled nursing visits. 
 
You asked the Plan to pre-approve homecare skilled nursing visits. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
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 homecare skilled nursing visits. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the home health aide 
services are not medically necessary for your current injury status based on the provided documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of homecare skilled nursing visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve homecare skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on March 29, 2021. 
 
You asked the Plan to pay for dental code D0330. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says panoramic x-rays are not covered under the 
Plan's supplemental benefit. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the panoramic x-ray is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-
ray (D0330) provided on March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (L3060, L3500, L3040, L3510) provided December 31, 2020.
You asked the Plan to pay for foot orthotics. You say that you were told these items would be covered. 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 pay for foot orthotics (L3060, L3500, L3040, L3510) provided December 31, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance for the bronchoscopy, rigid or flexible, including fluoroscopic guidance (31653) provided on January 5, 2021.
You asked the Plan to adjust the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service provided.
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 diagnostic procedures and tests provided at an outpatient hospital.
You have been asked to pay $679.53 (Plan allowed amount of $3,397.66 x 20% coinsurance) for the diagnostic test/procedure provided at an outpatient hospital. 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 adjust the coinsurance for the bronchoscopy, rigid or flexible, including fluoroscopic guidance (31653) provided on January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81291, 81226, 81227, 81225) provided 
August 27, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code 81291, 81226, 81227, & 81225 is not supported in the medical record. Specifically if 
one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the 
laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte 
assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. If no CPT 
code accurately describes the procedure performed, the laboratory may report CPT code 81479. In this case, multiple 
unbundled codes were billed for the same service. Based on this information, we decided that Medicare rules 
for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay 
for genetic testing (81291, 81226, 81227, 81225) provided August 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve infusion of Injectafer and injection services.
You asked the Plan to pre-approve infusion of Injectafer and injection services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 infusion of Injectafer and injection services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the provided record does not indicate that the requested service is medically necessary or reasonable, as defined by Medicare rules. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of infusion of Injectafer and injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve infusion of Injectafer and injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Revita and skin graft procedures. 
 
You asked the Plan to pre-approve Revita and skin graft procedures. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat or alternative applications of skin substitute 
grafts are not considered medically reasonable and necessary when a previous full course of applications was 
unsuccessful. 
 
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 Revita and skin graft procedures. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found due to the wound 
responding to prior treatment, albeit slowly, and that the wound itself has necrosis and pus, the criteria for 
Revita is not met at this time, based on the provided documentation. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Revita and skin graft procedures have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Revita and skin graft procedures.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the outpatient surgery services provided on February 23, 2021.

You asked the Plan to waive the copay for the services provided. You say that the plan overpaid for the services. The Plan denied your request. The Plan says the claim was processed 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 $225 copay for outpatient surgery at an ambulatory surgical center. 

The file shows that you received joint injections. These services are considered outpatient surgery services. The claim was billed as completed in an ambulatory surgical center. You have been asked to pay a $225 copay for the services provided. The services fall within the outpatient surgery 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 copay for the outpatient surgery services provided on February 23, 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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 receive acute critical care services and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. 

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. Specifically, medically necessary services are being obtained at the enrollee's current level of care.

This means admission into a LTACH is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a lower partial denture (D5214).
You asked the Plan to pre-approve a lower partial denture. You say that you have a diet that you have to follow
and need to be able to chew the food. The Plan denied your request. The Plan says that rules for coverage have
not been met because you have 1 or more teeth that are not healthy enough to support the requested item.
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 a lower
partial denture when the services are medically necessary and reasonable.
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 lower partial denture. Our reviewer
says that the requested item is medically necessary for you. Our physician reviewer found that the treating
physician's narrative, including the initial exam, regional exam, soft issue cancer exam, and consultation with
patient, were incomplete. The available documentation in the case file is incomplete and does not support the
Plan's denial.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of a lower partial denture have been met. Therefore, we decided that the Plan has
to pre-approve a lower partial denture (D5214).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member does not have complex nursing, medical management, and rehabilitation needs that cannot be met at a less intensive level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The patient was admitted for a fall and a knee effusion. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on March 9, 2021.
You asked the Plan to pay for bitewing x-rays. You say that this should be covered. The Plan denied your
request. The Plan says this is not included in your dental benefits.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for bitewing
x-rays (D0274) provided on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on February 10, 2021.
You asked the Plan to waive the copayment for the urgent care visit. You say that this visit should be free because you had a Covid test. The Plan denied your request. The Plan says you have been asked to pay 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 a $50 copayment per visit for Medicare-covered urgently needed services.
You have been asked to pay a $50 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The record shows you were not charged for the Covid-test but were charged for other services. 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 urgent care visit provided on February 10, 2021.