Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services for the enrollee.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says it is not necessary for the enrollee to receive daily skilled services on an inpatient basis.
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. Continued services beyond March 25, 2020 were requested for 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 continued services. Our physician reviewer found that from a nursing perspective, the enrollee has stable vital signs, and her lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee requires varying assist with activities of daily living. 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the radiofrequency ablation (RFA) rendered to you on November 14, 2019 and November 25, 2019.
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 covered.
The Plan must follow Medicare rules. The rules say that no more than two RFA sessions are covered every 12 months. We looked at the file and Medicare rules. The file shows that you previously had RFA on April 29, 2019 and May 20, 2019 for which the Plan approved and paid. The services on November 14, 2019 and November 25, 2019 exceeded the amount allowed by Medicare. Therefore, we decided that the Plan does not have to pre-approve the radiofrequency ablation (RFA) rendered to you on November 14, 2019 and November 25, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the physical therapy visits provided from September 22, 2019 to October 14, 2019.
You asked the Plan to waive the cost share for the physical therapy visits. You say that you were not told the provider was out-of-network. 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. Your contract with the Plan says that there is a $750 deductible that applies towards out-of-network physical therapy visits and 30% coinsurance after the deductible is met for each therapy visits. The physical therapy visits you asked the Plan to waive the cost share for falls within the "Outpatient rehabilitation services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies to out-of-network physical therapy visits and 30% coinsurance after the deductible is met for each therapy visits. The record shows the provider is out-of-network. See chart below.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on September 17, 2018 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that these services were needed for the patient's hypertension. The Plan denied your request. The Plan says no prior authorization was obtained.
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 for an office visit provided on September 17, 2018 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has been in the hospital for a while and still needs high levels of oxygen. It would be best to receive the continued care in a hospital that specializes in long term acute care. The Plan denied your request. The Plan says an LTACH cannot provide any services that cannot be adequately provided by the current facility.
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 is a 72 year old female who was admitted to the acute hospital on 3/10/2020 with increased edema and shortness of breath. Her diagnoses include acute on chronic respiratory failure with hypoxia, hypercapnia, and congestive heart failure. She has been treated in the hospital with Vapotherm at 70% oxygen, diuretics, nebulizers and steroids. Her blood pressures have been unstable - reportedly with systolic pressures ranging from the low 80's to 160's. She continues to require high flow oxygen and she is weak and deconditioned and requires physical and occupational therapy services. Transfer to a long term acute care hospital (LTACH) is requested. Based on the provided medical records the acute care hospital is able to provide all of the services the patient requires. The patient continues to have unstable blood pressure readings and does not appear medically stable for transfer based on the records provided. Continued care at the acute hospital level is appropriate until the patient is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for the Accu-Check Aviva Plus.
You asked the Plan to pre-approve the tier exception. You say that this is medically necessary. The Plan denied your request. The Plan says tier exceptions only apply to Part D drugs.
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of the tier exception have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for the Accu-Check Aviva Plus.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no expectation of further progress until release by the doctor to use full weight on the fractured knee.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of care with an out of network vascular surgeon.
You asked the Plan to pre-approve the continuation of care with an out of network vascular surgeon. You say that the doctor performed a bypass procedure on his right leg in 2014. The Plan denied your request. The Plan says Optimum has in network vascular surgeons available in the enrollee's service area that can provide the services at issue in this request.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for 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 continuation of care with an out of network vascular surgeon. Our reviewer says that the criteria for coverage of out of network care have not been met. Our physician reviewer found the enrollee notes he has not seen the provider he is requesting since 2016. According to the most recent vascular evaluation performed on December 12, 2019, the enrollee's leg was asymptomatic with respect to peripheral artery disease. The graft appeared to be patent as a recent duplex
demonstrated absence of stenosis. The plan was for routine follow-up in 6 months. As the enrollee is having no active issues with respect to his bypass and has not seen the provider in question since 2016, continuity of care is not 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 the continuation of care with an out of network vascular surgeon have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of care with an out of network vascular surgeon.
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 a delay in transferring the enrollee to an LTACH will directly jeopardize the ability to fully recover and successfully regain maximum independence. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a lower extremity stent for the enrollee.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the enrollee does not have symptomatic arterial disease.
The Plan follows Medicare rules. Medicare rules say that non-coronary vascular stents are only covered under certain medical indications. 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 services. Our physician reviewer found that the enrollee has a history of aortobifemoral and bilateral femoral popliteal bypass grafts. Duplex demonstrates elevated velocities consisted with greater than 75% stenosis of the proximal portion of the left femoral popliteal bypass graft. The indication for treatment is not for symptomatic relief, but for preservation of the bypass as a high grade stenosis threatens the patency of the bypass. If the bypass graft thromboses, the treatment would be emergent, far more complex, and significantly elevates the risk of limb loss. The whole point of graft surveillance is to identify these graft threatening lesions and treat prior to graft thrombosis. Therefore, the requested services are medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have been met. Therefore, we decided that the Plan has to pre-approve a lower extremity stent.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on April 15, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You sent your Explanation of Benefits in for review. 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 a $100 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $100 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" 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 the emergency room visit provided on April 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for cane and grab rail purchased on August 6, 2019 to August 20, 2019 from out of network (OON) providers.
You asked the Plan to pay for the cane and grab rail. You say that please forgive your lack of knowledge in regards to in-network vendor requirements. You look forward to whatever you may be entitled to regarding reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. . If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. The plan cannot pay a provider who is not eligible to participate in Medicare.
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 Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. The requested providers in this case are not 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 for cane and grab rail purchased on August 6, 2019 to August 20, 2019 from out of network (OON) providers.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the laboratory work provided on October 3, 2019.
You asked the Plan to waive the deductible for the laboratory work. You say that you have not been charged for lab tests previously. You say you do not know why the lab procedures were not covered. 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. Your contract with the Plan says that there is a $300 deductible that applies towards in-network laboratory services. The laboratory work you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible that applies towards in-network laboratory work. This cost sharing is a contractual obligation that had not been met at the time the laboratory work was received on October 3, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory work provided on October 3, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for home health services provided to the enrollee on May 13, 2018.
You asked the Plan to pay for the services. You say that no authorization should be required. The Plan denied your request. The Plan says that the information received did not show that the enrollee had a skilled nursing need for this visit.
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 send MAXIMUS any medical records to substantiate their denial, which was based on medical necessity. The plan's denial is twofold, saying that the information received did not show: -The member had a skilled nursing need for nursing home visit -The nursing visit was medically necessary The information we received did not contain any medical records or clinical information. The plan has not substantiated their denial as medical records would be required to make the denial argument above. Therefore, we decided that the Plan has to pay for home health services provided to the enrollee on May 13, 2018.
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 a short-latency somatosensory evoked potential (SSEP) study (95925) provided on September 17, 2019.
You asked the Plan to pay for a SSEP study. You say that this code is supported by the records. The Plan denied your request. The Plan says the records do not contain documentation of this service.
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 95925 is short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs. 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 a SSEP study. Our reviewer says that the billing of CPT 95925 is not supported. Our physician reviewer found there is no clear documentation that shows SSEP studies of the upper extremities were performed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a SSEP study have not been met. Therefore, we decided that the Plan does not have to pay for a short-latency somatosensory evoked potential (SSEP) study (95925) provided on September 17, 2019.