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

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing
facility, home with home health and home physical therapy.

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 complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for a leg burn and COVID-19 pneumonia. Medical problems are stable. There are no complex
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical
record supports a need for physical and/or occupational therapy, there is no documented need for intensive
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).

You asked the Plan to pre-approve SNF care. You say that you are appealing this denial. The Plan denied your
request. The Plan says the denial of authorization for SNF care is correct.

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 you do not have daily skilled nursing needs
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have
daily skilled therapy needs that require specialized skill, knowledge, and judgment of a skilled professional
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled
Nursing Facility (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 admission to a Skilled Nursing Facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular nerve stimulator.

You asked the Plan to pre-approve the stimulator. You say that you have a long history of chronic pain. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is not a covered Medicare benefit. 

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 stimulator. Our reviewer says that Our physician reviewer found.

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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular nerve stimulator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve testosterone gel 1.62% (J3490).

You asked the Plan to pre-approve testosterone gel. You say that the medication is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.

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 testosterone gel 1.62% (J3490).
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 a Freestyle Libre CGM. You say that this is necessary to keep the enrollee off medication. The Plan denied your request. The Plan says the criteria for coverage 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 indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chiropractic office visit.
You asked the Plan to pre-approve the visit. You say that this is needed for neck pain. The Plan denied your request. The Plan says coverage extends only to treatment by means of manual manipulation of the spine to correct a subluxation.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve a chiropractic office visit.
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. The Plan denied your request. The Plan says IRF admission is 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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for uremic encephalopathy, metabolic acidosis, and acute on chronic respiratory failure. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta for the enrollee.

You asked the Plan to pre-approve Neulasta. You say that Neulasta is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Neulasta (Pegfilgrastim). The Maximus Physician Reviewer determined that the use of Neulasta is supported by clinical research that appears in a CMS-approved medical journal. The Plan argues that there is no established evidence to support the use of long-acting Neulasta (Pegfilgrastim) for febrile neutropenia prophylaxis which is related to immunosuppressive therapy after a renal transplant. The medical records show the enrollee has undergone a kidney transplant. The enrollee received organs that were positive for hepatitis C. Antiviral medications were administered. The enrollee was found to have neutropenia which continues. The enrollee's ANC was 650. The enrollee's medications include Prograf (Tacrolimus) and prednisone. Our Medical Director has concluded that the Plan is correct in this case. There is insufficient evidence to support the use of Neulasta (Pegfilgrastim) in patients who have undergone renal transplant.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have to pre-approve Neulasta 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 monitor. You say that this is not medically necessary. The Plan denied your request. The Plan says this is 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 the monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a requirement for insulin to cover the monitor, so the criteria is not met. The records do not show what the blood glucose information is being used for.

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (S9328) provided March 30, 2020 to September 30, 2020.

You asked the Plan to pay for the home infusion services. You say that the services were medically necessary. The Plan denied your request. The Plan says the CPT code billed is not eligible for Medicare payment.

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 S9328 is not supported in the medical record. Specifically, per the CMS National Physician Fee Schedule, this code has a status indicator of "I" which means it is ineligible for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion services (S9328) provided March 30, 2020 to September 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that this device is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a continuous glucose monitor (CGM). The Maximus Physician Reviewer determined that the requested system was considered medically reasonable and necessary in this case. The Plan argues that the enrollee does not meet all of the required criteria for this device. Our Medical director has concluded that the Plan is correct in this case. The available documentation does not sufficiently support that the enrollee's insulin treatment regimen requires frequent adjustment by the enrollee on the basis of BGM or CGM testing results.

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 continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on January 6, 2021.

You asked the Plan to waive the deductible for the office visit. You say that the provider is in-network. 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. Your contract with the Plan says that there is a $750 deductible towards out-of-network office visits.

The office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category provider. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards out-of-network office visits. The record shows the provider is out-of-network. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on January 6, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on January 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive cardiovascular panel (81286, 81404, 81407, 81408, 81479) provided on September 16, 2020.

You asked the Plan to pay for a comprehensive cardiovascular panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease.

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive cardiovascular panel have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive cardiovascular panel (81286, 81404, 81407, 81408, 81479) provided on September 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on November 12, 2020.
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you were told that you would not owe anything. The Plan denied your request. The Plan says the correct coinsurance has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for durable medical equipment. You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $99.24. The total amount you are being asked to pay is $19.85 ($99.24 x 20% = $19.85). The correct coinsurance has been applied to the durable medical equipment that was provided. Durable medical equipment falls within the durable medical equipment benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on November 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on October 16,
2020, by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that this service was medically
necessary. The Plan denied your request. The Plan says this service was rendered by a non-contracted provider.
The Plan also says that prior authorization was not 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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on
October 16, 2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 2, 2020.

You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically
necessary. The Plan denied your request. The Plan says there is no history of an office visit conducted to show
the ordering provider could have diagnosed or treated the member for any issues requiring the orthoses.

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 the lumbar-sacral orthosis (L0650). Our
reviewer says that the orthosis is not medically necessary. Our physician reviewer found the available
documentation in the case file does not support that the requested lumbar-sacral orthosis (LSO) was medically
reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the
LCD. An appropriate history and a physical examination of the back would reasonably be required to
adequately assess whether the coverage criteria for an LSO have been met. The documentation does not
support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as
there is insufficient documentation of an appropriate evaluation of the enrollee and no documentation of a
credible physical examination of the back.

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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided
that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies for a therapeutic CGM (K0553) provided on October 14, 2020.

You asked the Plan to pay for supplies for a CGM. You say that the enrollee is using the requested medically necessary items with benefit. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the document submitted as proof of delivery indicates a need for a signature. No signature was provided. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for supplies for a therapeutic CGM (K0553) provided on October 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on July 28, 2020.

You asked the Plan to waive the coinsurance for durable medical equipment. You say that you do not agree with this coinsurance. The Plan denied your request. The Plan says the correct coinsurance has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for durable medical equipment.

You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $306.31. The total amount you are being asked to pay is $61.26 ($306.31 x 20% = $61.26). Durable medical equipment falls within the durable medical equipment benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on July 28, 2020.