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

We decided that the Plan does not have to pay for medical supplies (A6196, A6197, A6252) provided August 21, 2020 to September 18, 2020.

You asked the Plan to pay for the medical supplies. You say that the items were medically necessary. The Plan denied your request. The Plan says the claim was not filed correctly.

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 codes A6196, A6197, & A6252 are not supported in the medical record. Specifically, place of service 31 was billed on the claim. Payment for these items is included in the Part A SNF payment. Based on this information, we decided that Medicare rules for coverage of the medical supplies have not been met. Therefore, we decided that the Plan does not have to pay for medical supplies (A6196, A6197, A6252) provided August 21, 2020 to September 18, 2020.
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 the care can be safely received in another setting, such as a skilled nursing 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 currently undergoing treatment at an acute care hospital (ACH). The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.

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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a Botox injection for the enrollee.
You asked the Plan to pre-approve a Botox injection. You say that this injection is medically necessary. The
Plan denied your request. The Plan says that the enrollee did not try and fail oral therapy.
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. However, in the case material the Plan did not specific which oral drugs were to be tried
and failed. 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 Botox injection. Our reviewer
says that Medicare coverage criteria are met. Our physician reviewer found in this case Botox is noted to be
supported for use in sialorrhea which is the diagnosis. In this setting it can be concluded that the requested
medication would be considered to be 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 a Botox injection have been met. Therefore, we decided that the Plan has to preapprove
a Botox injection for the enrollee.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan with quantitative evaluation of coronary calcium (75571).

You asked the Plan to pre-approve a CT scan with quantitative evaluation of coronary calcium. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered service and will be denied as not medically necessary. 

We looked at the file and Medicare rules. The requested service is not a covered benefit. Based on this information, we decided that Medicare rules for coverage of a CT scan with quantitative evaluation of coronary calcium have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan with quantitative evaluation of coronary calcium (75571).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for inpatient care for social placement for the enrollee.

You asked the Plan to provide coverage for acute inpatient hospital care. You say that inpatient admission was medically necessary.The Plan denied your request. The Plan says inpatient coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for continued inpatient hospital care. The Maximus Physician Reviewer determined that the requested services were medically reasonable and necessary in this case. The reviewer found that the enrollee was admitted to the hospital with severe debility due to alcohol abuse. She needed extensive physical therapy. She had tested positive for COVID-19 and needed skilled nursing facility placement. The Plan requested a re-opening stating an inpatient level of care was not required. Our Medical Director concluded the Plan is correct in this case. Continued inpatient hospital care for this enrollee was no longer at issue at the time of the Maximus decision as the enrollee was discharged to a skilled nursing facility at the point. 

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 care have been met.Therefore, we decided that the Plan does not have to provide coverage for inpatient care for social placement for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in bathtub.
You asked the Plan to pre-approve the bathtub. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk-in bathtub.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for braces.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a contract 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral out-of-network for braces.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that 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 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. Our physician reviewer found the documentation does not support that the complexity of your nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied
your request. The Plan says rules for IRF care have not been met.

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. Our
physician reviewer found that you are a 71-year-old female who was admitted to an acute hospital on April 21,
2021, with a femur fracture. In this case, you have remained medically stable without any daily skilled nursing
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational
therapy, at an intensive rehabilitation therapy program. While you continue to have a need for skilled therapy
with ongoing safety concerns and a potential for functional improvement, the documentation does not support
that you would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication
that you would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under
the supervision of a physician with at least 3 visits weekly to regain or maintain her functional status. You have
an order for no weight bearing on the involved lower extremity. You are able to receive skilled rehab services
at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prochlorperazine 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 this drug is self-administered.

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 Prochlorperazine for the
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that this provider has a full understanding of your medical history and records. You state this is the best person to continue providing you with care to ensure that your condition does not worsen. The Plan denied your request. The Plan says your eye condition is stable and it is safe to transfer the care to an in-network 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation mileage.
You asked the Plan to pre-approve the additional mileage. You say that you and your spouse no longer drive. The Plan denied your request. The Plan says transportation over 50 miles is not covered.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation up to 50 miles one-way per trip. We looked at your request, the records in the case file, and the rules. Your requested trip is over 50 miles one-way. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional transportation mileage.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for an inpatient hospital stay for a total knee arthroplasty for the enrollee.

You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee is medically stable, and has been provided clearance to undergo this elective procedure.

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 midnight. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnight 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 pay for acute inpatient hospital care. 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 being treated for unilateral primary osteoarthritis of the knee. She presented with persistent, worsening left knee pain that has now failed conservative treatments. The exam reveals she walks with a limp favoring the left lower extremity. There is valgus deformity with mild effusion. Range of motion is 3 to 100. There is significant medical history of hyperlipidemia and hypertension. There is also documentation of a blood clot having occurred post bunion procedure of the foot. These comorbidities, in combination with the history of perioperative complication (after a less intensive surgical procedure) indicates a significantly increased risk for complications. The enrollee indicated for significant orthopedic surgery involving anesthesia, prolonged recumbency and fluid exchanges. There is reasonable documentation provided to support the expectation that the enrollee with require a greater than 2 midnight stay. This includes for pain control, along with enhanced cardiopulmonary and neurovascular assessments. Therefore, the request for inpatient hospital stay for a total knee arthroplasty is 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for an inpatient hospital stay for a total knee arthroplasty for the enrollee.

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 waive the co-payment for a Teladoc visit provided on November 20, 2020.

You asked the Plan to waive the co-payment for Teladoc visit. You say that you feel that this co-payment should be waived as your primary care provider cannot handle this situation. The Plan denied your request. The Plan says the co-payment amount you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $45 co-payment for Teladoc visit.

You have been asked to pay $45 co-payment for Teladoc visit. Teladoc visit falls within the Remote Access Technologies 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 co-payment for a Teladoc visit provided on November 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PureWick external catheter system (A4335).

You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary considering your condition. The Plan denied your request. The Plan says this is non-reusable and not covered.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve the PureWick external catheter system (A4335).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that 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. 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 medically necessary. Our physician reviewer found the enrollee presented to the hospital with cough and shortness of breath. The note states she is doing well with no complaints. The chest x-ray showed improvement of infiltrate and finished five days of antibiotics. The complexity of her nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Her current medical condition does not require intensive physician or nursing supervision in an IRF. She may benefit from further therapy but does not require an intensive therapy program in an IRF.

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.