Persius/hicric huggingface dataset:
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 admission to an IRF is medically necessary for this enrollee. The Plan denied your request. The Plan says the records do not indicate that the enrollee requires an intensive therapy program with multiple visits from a rehab doctor each week. The necessary services can be provided in other settings.

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 does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. 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. Medically necessary services can be provided in a different 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes (CPT code G0299).

You asked the Plan to pre-approve the home health services. You say that you need skilled nursing services and your wound is still fourteen (14) centimeter's deep. The Plan denied your request. The Plan says the medical records submitted with this request do not show any update to your treatment plan and you have not seen your treating doctor for follow-up regarding your wound.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 home health services. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. You have had prior skilled nursing (SN). Per documentation, you were approved eighteen (18) additional SN visits with a separate request to a new home health agency as the wound has progressed. The documentation does not reveal a treatment plan or plan of care reviewed by a physician for the requested SN visits. For these reasons this request 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes (CPT code G0299).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee requires an inpatient stay and close physician supervision. The Plan denied your request. The Plan says the enrollee does not need an intensive team for care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute care hospital for an ankle fracture and a seizure. Her medical conditions are stable. There are no complex nursing needs. She does not require treatment by multiple therapies in an intensive rehabilitation therapy program. She does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869, 22870, 77003 and 01992), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the enrollee would benefit from the procedure so that the enrollee could their daily routine and they are not a candidate for a more invasive procedure. The Plan denied your request. The Plan says the services are considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869, 22870, 77003 and 01992), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.

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. Medicare rules say that a total electric hospital bed is not covered.

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital
bed.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.

You asked the Plan to pre-approve the requested LDCT scan. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.

The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria. 

We reviewed the file and the Medicare rules. The file shows that the enrollee is not aged 55 to 77. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
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 need help to stand and walk, and you are struggling at home and feel that your current therapy sessions are not enough. The Plan denied your request. The Plan says the necessary care can be provided in another setting.

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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath/shower chair.

You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your request. The Plan says the request is a convenience item.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation therapy for liver cancer using two (2) treatment(s) of SIRT (CPT code 77778), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of SIRT using y-90 microspheres in the setting of metastic stage intravenous (IV) adenoid cystic cancer have not been demonstrated in the peer-reviewed literature.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found it is not clear from the records why this patient enrollee is being offered repeat radioembolization. For liver metastases, a complete radiographic response would not typically be expected from any therapy. Conceivably, a partial response can be durable and is not indicative of treatment failure of the need to retreat. A "partial response" would not be an evidence-based rationale to deliver a second radioembolization with potential severe toxicity risks. Notably in the appeal letter there are several citations, none of which support retreatment in the setting of partial response. Our physician reviewer's decision is unfavorable due to the lack of demonstration of need, and as the treatment offered would not be furnished in accordance with accepted standards of medical practice.

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 radiation therapy for liver cancer using two (2) treatment(s) of SIRT (CPT code 77778), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Foundation One testing rendered on December 15, 2020.

You asked the Plan to pay for 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 genetic testing procedures submitted under code 81455 are denied as not medically necessary. 

We looked at the file and Medicare rules. The services at issue are genetic testing billed under code 81455. These services are denied by Medicare. Therefore, we decided that the Plan does not have to pay for the Foundation One testing rendered on December 15, 2020.

Local Coverage Article (LCA) A54795 referenced by the Plan is not valid for the state of Massachusetts where the testing was performed and was not used in the MAXIMUS determination.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for an office visits with an out-of-network provider.

You asked the Plan to pre-approve the referral. You say that the enrollee would like to maintain continuity of care. The Plan denied your request. The Plan says there are no out-of-network benefits.

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 for an office visits with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upright walker for the enrollee.

You asked the Plan to pre-approve an upright walker. You say that the enrollee has a regular walker with a seat but requires an upright walker due to the height of the regular walker being too low for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that the enrollee has a regular walker. In addition, the enrollee was also recently approved for a rollator walker on May 4, 2021. The enrollee's current regular walker and rollator walker serve the same purpose as an upright walker. The documentation shows that a regular walker can accommodate enrollees up to six feet tall. The documentation shows that the enrollee is less than six feet tall. Therefore, we decided that the Plan does not have to pre-approve an upright walker for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights 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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the shoulder replacement surgery may be safely performed with a 48-hour observational stay. Inpatient admission is not 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's rehab needs does not require an intensive team for functional goals.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute care hospital for lumbar spinal surgery. His medical conditions are stable. There are no complex nursing needs. He does not require treatment by multiple therapies in an intensive rehabilitation therapy program. He does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on February 23, 2021 by an out of network (OON) provider.

You asked the Plan to pay for home health services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says 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 had network providers available who could have provided 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 home health services provided on February 23, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided on February 8, 2021, and February 24, 2021.
You asked the Plan to waive the copayments for specialist visits. You say that you disagree with the charges because these were follow-up visits and you were told you would not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $10 copayment for specialist visits. You had specialist visits on February 8, 2021, and February 24, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay a $10 copayment per each visit. The total amount you owe is: $20. You have been asked to pay the total copayment amount of $20 for specialist visits. Specialist visits fall within
the physician/practitioner services, including doctor's office visits 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 copayments for specialist visits provided on February 8, 2021, and February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on August 26, 2020 by an out of network (OON) provider.

You asked the Plan to pay for pathology services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 had network providers available who could have provided 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 pathology services provided on August 26, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on February 4, 2021.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct 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 20% coinsurance for Medicare Part B prescription drugs. 

You received Medicare Part B drugs on February 4, 2021. The total allowed amount is $381.18 and 20% of that is $76.23.

You have been asked to pay the total coinsurance amount of $76.23 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 Medicare Part B drugs provided on February 4, 2021.