Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were never told that you would have a copayment for this. The Plan denied your request. The Plan says the correct copayment 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 $380 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care/in-network.

You have been asked to pay a $380 copayment per day for days 1-3 for an inpatient hospital stay. The total amount you are being asked to pay is $1,140 ($380 x 3 days = $1,140). An inpatient hospital stay falls within the inpatient hospital care/in-network 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 inpatient hospital stay provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a raised toilet seat.

You asked the Plan to pay for a raised toilet seat. You say that the coding was incorrect. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature.

While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a raised toilet seat.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FoundationOne genetic testing.

You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this testing is very broad and non-covered.

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 the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you were diagnosed with cholangiocarcinoma in the fall of 2020. Testing specifically related to cholangiocarcinoma, for which associated therapies are known, is medically necessary and reasonable. Panel testing, inclusive of testing that is not related to cholangiocarcinoma or for which there are no associated therapies, is not medically necessary or reasonable. The documentation does not support that the requested panel testing is medically necessary or reasonable.

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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve FoundationOne genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the digital hearing aids (V5244 x 2).

You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable as they were purchased from an out of network provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.

We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, the hearing aids were purchased from an out of network provider. The Plan benefit states that coverage includes up to two hearing aids every year; however, you must see an in-network provider to use this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for the digital hearing aids (V5244 x 2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for
coverage of a LTACH admission.

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 that the enrollee was admitted for acute respiratory failure and sepsis due to a
retropharyngeal abscess/mediastinitis. The enrollee suffered cardiac arrest from a tension pneumothorax. She
underwent a recent washout and had a wound vacuum-assisted closure (VAC) in place, with the latest wound
VAC replacement. A percutaneous endoscopic gastrostomy tube was inserted and a
tracheostomy was performed. There are plans to get a bronchoscopy and send for bronchoalveolar lavage
cultures.

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 she 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental bone graft.

You asked the Plan to pre-approve the dental bone graft. You say that bone needs to be added to the jaw, as the
enrollee cannot chew evenly. The Plan denied your request. The Plan says neither Medicare nor this Medicare
Advantage Plan covers items and services in connection with the care, treatment, filling, removal, ore
replacement of teeth or structures directly supporting the teeth.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a
dental bone graft.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incisional biopsy of oral tissue and DME.

You asked the Plan to pay for the incisional biopsy of oral tissue and DME. You say that you would like the biopsy service to be covered. The Plan denied your request. The Plan says the treating provider has opted out of Medicare. The Plan also says that the treating provider is not a Medicare enrolled provider and is not eligible for reimbursement from Medicare for services rendered.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the incisional biopsy of oral tissue and DME.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq.

You asked the Plan to pre-approve Tecentriq. You say that other medication was discontinued due to the
enrollee's reaction. The Plan denied your request. The Plan says the effectiveness of Tecentriq in the setting of
disease progression following prior PD-L1 treatment has not been demonstrated in the peer-reviewed literature.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Tecentriq. Our physician reviewer
found that the enrollee has stage IV non-small cell lung cancer. The requested use of Tecentriq is not supported
by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.
As the enrollee has progressed on Keytruda, a PD1 inhibiter, Tecentriq in same class of drug cannot be
approved per compendia. The documentation does not support that the requested drug is safe and effective and
otherwise reasonable and necessary for this 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 Tecentriq have not been met. Therefore, we decided that the Plan does not have
to pre-approve Tecentriq.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power tilt seating system for a wheelchair.

You asked the Plan to pre-approve a power tilt seating system. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. The requested accessory is not covered under the enrollee's Medicare benefit. Maximus does not have jurisdiction with regard to Medicaid benefits. Please contact the Plan to find out how to file an appeal of the denial of Medicaid benefits. Therefore, we decided that the Plan does not have to pre-approve a power tilt seating system for a wheelchair.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a FreeStyle Libre 14-day sensor.

You asked the Plan to pre-approve a FreeStyle Libre 14-day sensor. You say that the item is medically
necessary. The Plan denied your request. The Plan says that you do not meet the criteria for this item.

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. We were unable to determine medically necessity due to missing medical
records. Therefore, we decided that the Plan has to pre-approve a FreeStyle Libre 14-day sensor.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox 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 medical studies have not shown that this is helpful for treatment of gastroparesis.

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 the injection. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found though trials evaluating the effect of intrapyloric botulinum toxin injection on gastroparesis have been reported, there is no agreement whether botulinum toxin can effectively relieve the symptoms and improve the results of gastric emptying study in patients with gastroparesis.

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 Botox injection for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.

You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says the enrollee has not tried and failed Retacrit for at least two consecutive months, with appropriate dose adjustments.

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 Aranesp. Our physician reviewer found that the enrollee has a history of iron deficiency anemia. The requested drug is not being used under the medically-accepted standards of practice. In addition, the Plan requires a trial of Retacrit before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating that the plan's required drug 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prostrate artery embolization (CPT code 37243).

You asked the Plan to pre-approve the services. You say that this is the best procedure for your condition
according to the research you have done. The Plan denied your request. The Plan says the services are
considered experimental and investigational.

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 the services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found prostatic arterial embolization (PAE) is an experimental technique to treat symptomatic BPH.
Very limited studies have demonstrated possible short-term safety and efficacy. The most recent AUA
guidelines do not recommend this procedure outside of a clinical trial 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a prostrate artery embolization (CPT code 37243).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve 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 a therapeutic CGM is covered when specific criteria are met.

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 enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has type II diabetes and is maintained on medical therapy, including insulin. Per the documentation he does not perform frequent (four or more times a day) testing; is not insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump; and his regimen does not require frequent adjustment by the beneficiary on the basis of BGM or CGM testing results. The criteria for coverage are not met and the CGM 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 pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consumer directed personal assistance services
(CDPAS).

You asked the Plan to pre-approve CDPAS. You say that these services are necessary for you. The Plan denied
your request. The Plan says that these services are not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that custodial care, such as CDPAS services, is not
covered. Therefore, we decided that the Plan does not have to pre-approve consumer directed personal
assistance services (CDPAS).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897) 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 the use of Prolia is only supported for males if receiving androgen deprivation therapy for non-metastatic prostate cancer.

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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Prolia use is only supported for males if receiving androgen deprivation therapy for nonmetastatic prostate cancer. The review has determined that the documentation does not support that the Prolia is medically reasonable or necessary for the enrollee. The documentation does not support that the Prolia is safe and effective 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 Prolia (J0897) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the requested device. You say that you hate pricking your hand several times a day. The Plan denied your request. The Plan says coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation does not indicate that you perform blood glucose testing at least four times per day, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve immediate dentures (D5222).

You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve immediate dentures (D5222).
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 the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower 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 physician reviewer found that the enrollee was admitted to the acute hospital for confusion, pleural effusion and urinary tract infection. His medical problems are stable. There are no complex nursing needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program.

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.