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

We decided that the Plan does not have to pre-approve an outpatient office visit, Methylprednisolone, and
Hyaluronic acid.
You asked the Plan to pre-approve the outpatient office visit, Methylprednisolone, and Hyaluronic acid. You
say that these injections should be covered as a medically necessary service due to your pain. The Plan denied
your request. The Plan says the documentation does not support the need for these drugs.
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 outpatient office visit,
Methylprednisolone injection, and Hyaluronic acid. Our reviewer says that the Methylprednisolone and
Hyaluronic acid do not meet coverage criteria. Our physician reviewer found the records do not support that the
Methylprednisolone and Hyaluronic acid are medically reasonable and necessary for you. Our reviewer found
that the records does not support that the Methylprednisolone and Hyaluronic acid are safe and effective for
you.
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 outpatient office visit, Methylprednisolone injection, and Hyaluronic acid
have not been met. Therefore, we decided that the Plan does not have to pre-approve an outpatient office visit,
Methylprednisolone, and Hyaluronic acid.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment forthe ER visit provided from May 24, 2019 through May 25, 2019.You asked the Plan to waive the copayment forthe ER visit. You say that you were told to go to the hospital. You say that you shouldn't be held responsible for the copayment.The Plan denied your request. The Plan says that the copayment applied correctly.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 Evidence of Coverage was not submitted. This means that the plan has not shown that the copayment amount you are being asked to pay is correct.Therefore, we decided that the Plan has to waive the copayment forthe ER visit provided from May 24, 2019 through May 25, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically reasonable and necessary as described above. 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 enrollee is medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician or a need for acute rehabilitation nursing care. Functionally given the enrollee has been at the same dependent level for two weeks; a short IRF stay will not change her level remarkably. The enrollee may benefit from further physical and occupational therapy but does not require an intensive therapy program. An IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the heart monitor removal procedure provided on March 27, 2019.
You asked the Plan to waive the copayment for the heart monitor removal procedure. You say that the sum of $325 was not settled in the bill for this procedure. You say you have no money to settle the account and would like the Plan to clear it. 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 $325 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $325 copayment for the heart monitor removal procedure. The heart monitor removal procedure falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 heart monitor removal procedure provided on March 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical magnetic resonance imaging (MRI) services.
You asked the Plan to pre-approve the cervical MRI. You say that the records provided support the need for the requested MRI. The Plan denied your request. The Plan says the clinical information provided does not indicate that the criteria for coverage have been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 cervical MRI. Our reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found the enrollee reported low back and right hip pain with radiation to the groin and thigh but no paresthesia and normal bowel and bladder function. No physical examination was possible for the series of visits when she continued to complain of these symptoms which were suggestive of a hip etiology and possible lower back etiology. There was no indication from the notes that there was a cervical spine issue such as infection, nerve impingement, fracture, tumor, or other red flag diagnosis which might warrant MRI at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cervical MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical magnetic resonance imaging (MRI) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Magnetic Resonance Imaging (MRI) provided on October 25, 2019.You asked the Plan to waive the copayment for MRI. You say that the provider did not inform you prior to service that you would be responsible for this amount.The Plan denied your request. The Plan says the copayment 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 copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $225 copayment for in-network MRI. You have been asked to pay the allowed amount of $189.28, which is less than the $225 copayment for MRI. MRI falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 Magnetic Resonance Imaging (MRI) provided on October 25, 2019.Your complaint regarding not being told about the cost-share for this service is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Prolia.
Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transurethral destruction of prostate tissue (53854).
You asked the Plan to pre-approve transurethral destruction of prostate tissue. You say that this is medically necessary. The Plan denied your request. The Plan says you have not been evaluated by the provider.
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 transurethral destruction of prostate tissue. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found medical necessity cannot be established because you have not been evaluated by his urologist to determine whether this procedure is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transurethral destruction of prostate tissue have not been met. Therefore, we decided that the Plan does not have to pre-approve transurethral destruction of prostate tissue (53854).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued dialysis care with an out-of-network provider.
You asked the Plan to pre-approve continued dialysis care with an out-of-network provider. You say that you
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee can
safely transfer to an in-network facility for dialysis.
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 continued dialysis care with an out-ofnetwork
provider. Our reviewer says that the enrollee can safely transfer to an in-network facility for dialysis.
Our physician reviewer found the enrollee is with ESRD and several co-morbid conditions including multiple
myeloma. The enrollee wishes to undergo hemodialysis closer to home due to issues with his transportation
(Driver is injured) and proximity due to perceived risk of Covid virus exposure.
The network provides a dialysis center within a very reasonable proximity to the enrollee's place of residence.
There are no recommendations and there is no medical reason why the risk of Covid infection would be
increased by driving any more number of miles, especially this amount of miles with no stops or increased
exposures. The request is not medically necessary at this time as the Plan has network providers who can
provide these 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 continued dialysis care with an out-of-network provider have not been met.
Therefore, we decided that the Plan does not have to pre-approve continued dialysis care with an out-ofnetwork
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor sensor and transmitter.
You asked the Plan to pre-approve the requested items. You say that it is in the enrollee's best interest to
continue with the device to prevent hospitalizations. The Plan denied your request. The Plan says the requested
items are non-covered.
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 the requested sensor and transmitter are not used with a non-therapeutic continuous glucose
monitor. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore,
we decided that the Plan does not have to pre-approve a continuous glucose monitor sensor and transmitter.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve pontics (D6245) for tooth #'s 11 and 12 and retainer crowns
(D6740) for tooth #'s 10, 13, and 14.
You asked the Plan to pre-approve the pontics and retainer crowns. You say that you would like these services
provided in order to prevent further emergency issues. The Plan denied your request. The Plan says that the
documentation does not explain why a denture cannot be used to replace your missing teeth.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the pontics
and retainer crowns when the services are medically necessary and reasonable.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the pontics and retainer crowns. Our
reviewer says that the pontics and retainer crowns meet coverage criteria. Our physician reviewer found
according to the EOC, fixed bridges are a covered expense. Our reviewer also found that since the abutment
teeth have good bone support and there are no other posterior teeth missing, a fixed bridge is medically
reasonable and necessary, rather than a removable partial denture to replace these missing teeth and return you
to good masticatory function.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the pontics and retainer crowns have been met. Therefore, we decided that the
Plan has to pre-approve pontics (D6245) for tooth #'s 11 and 12 and retainer crowns (D6740) for tooth #'s 10,
13, and 14.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an unspecified dental procedure.
You asked the Plan to pre-approve the dental procedure. The Plan denied your request. The Plan says the enrollee does not have dental benefits.
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 an unspecified dental procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from May 26, 2019 to June 24, 2019.You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from January 31, 2019 to August 4, 2019. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore,we decided that the Plan does not have to pay for the skilled nursing services provided from May 26, 2019 to June 24, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional Dexcom G5 Sensors (K0553).
You asked the Plan to pre-approve additional sensors. You say that you need this to be able to test your blood sugar. The Plan denied your request. The Plan says that Medicare does not cover more than one (1) sensor per month.
The Plan must follow Medicare rules. Medicare rules say that billing more than 1 UOS per 30 days of code K0553 will be denied as not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve additional Dexcom G5 Sensors (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6534 that were issued on February 13, 2020 to February 19, 2020.
You asked the Plan to pay for the compression stockings. You say that your doctor says you need these for venous ulceration management therapy and to manage edema. The Plan denied your request. The Plan says the stockings are examples of wound care items which are non-covered under the surgical dressing benefit because they do not meet the statutory definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6534 that were issued on February 13, 2020 to February 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit(99205)with the out of network (OON) provider.You asked the Plan to pre-approve the office visit. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says the requested provider is out of network; there are available in-network providers to render this service.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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service.Therefore, we decided that the Plan does not have to pre-approve an office visit(99205)with the out of network (OON) provider.
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 IRF services are medically necessary. The Plan
denied your request. The Plan says rules for coverage 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 above.
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 enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services
with regular physician evaluation. The enrollee's care needs can be met 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.