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 IRF services are medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The necessary services can be safely provided in an alternate level of 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 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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.  

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 continuous glucose monitor.  

You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee was recently hospitalized for suspected diabetic ketoacidosis and was found in an unconscious state. You say that the enrollee would benefit from having a continuous glucose monitoring system to help prevent such future episodes. 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 and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.  

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 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $70 ($35 each date of service) charged for specialist
services provided on February 24, 2021, and February 25, 2021
You asked the Plan to waive these copayments. You say that you do not believe these copayments are correct.
The Plan denied your request. The Plan says these copayments were charged based on the claim submitted by
your provider and the Plan contract agreement. Maximus overturned the Plans denial and instructed the Plan
waive these copayments. The Plan requested a reopen and stated that Maximus did not apply the correct
contract language. The Plan says that the provider was paid, and you were assessed a $70 liability for services
provided on each date of service. The Plan contract says that there will be a $35 each specialist visits provided.
The Plan is correct in this case. 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 $35 copayment for each specialist service.
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 $70 ($35 each date of service) charged for specialist services provided on February
24, 2021, and February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for any of the dental services provided on March 18, 2021.
You asked the Plan to pay for these dental services. You say that these dental services should be covered by the
Plan. The Plan denied your request. The Plan says the services provided were not covered. Maximus partially
overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says
regarding the services approved by the IRE, these services were denied because the frequency limitation has
been exceeded. A comprehensive oral evaluation or Periodontal Exam is covered once every three years. The
claim records show this benefit was exhausted on February 4, 2020.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan
offers a dental benefit in excess of Medicare coverage, the services provided were either excluded from
coverage or had their coverage frequency exhausted prior to the date of service. Therefore, we decided that the
Plan does not have to pay for any of the dental services provided on March 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided the Plan does not have to provide coverage for additional speech therapy visits for the enrollee
beyond those approved by the Plan.
You asked the Plan to provide coverage for additional speech therapy visits beyond those approved by the Plan.
You say that these services are medically necessary. The Plan denied your request. The Plan says Medicare
coverage criteria are not met. We partially overturned the Plans denial. The Plan requested a reopen and
stated that we did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for additional speech
therapy visits. Our Physician approved the request. The Plan has requested a reopen stating the IRE
did not follow in the Medicare Benefit Policy Manual Chapter 15, section 220.2 and 220.3.
The Plan also noted the IRE misinterpreted the quantity of reduced services as well as what has already been
approved. The Plan stated that 27 visits were initially requested. Of these, 8 visits were rendered at the time of
the appeal, leaving 19 sessions that were reviewed by the plan. Based on the documentation of improvement
after those 8 visits, an additional 10 visits were approved by the Plan on appeal. The Plan noted the denial of
the 9 excess visits was upheld by the Plan because additional visits cannot be authorized until there is a
progress report at least once every 10 treatment days illustrating objective improvement. Our Medical Director
has concluded that the Plan is correct in this case. It is stated in the Medicare Benefit Policy Manual Ch. 15,
Section 220.3, subsection D (Progress Report), under the Timing heading, that "The minimum progress report
period shall be at least once every 10 treatment days. The day beginning the first reporting period is the first
day of the episode of treatment regardless of whether the service provided on that day is an evaluation,
reevaluation, or treatment. Regardless of the date on which the report is written (and dated), the end of the
progress report period is either a date chosen by the clinician or the 10th treatment day, whichever is shorter."
Consequently, a determination regarding the additional days should not have been issued until another progress
report was submitted.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional speech therapy have not been met. Therefore, we decided that the
Plan does not have to provide coverage for additional speech therapy visits 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 admission to a SNF. You say that the requested SNF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, custodial and intermittent, can, as a practical matter, be provided 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 admission to a SNF 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not medically necessary.

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 admission is not medically necessary. Our physician reviewer found the enrollee was admitted for a total colectomy and ileostomy. The record indicates that the enrollee has had a prolonged hospital course and still requires acute care services. The enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the attendant control (E2331).  You asked the Plan to pre-approve the attendant control. You say that this item is medically necessary. The Plan denied your request. The Plan says an attendant control cannot be covered in addition to a beneficiary-operated joystick.  The Plan must follow Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the attendant control have not been met. Therefore, we decided that the Plan does not have to pre-approve the attendant control (E2331).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device and related accessory.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says medical necessity criteria have not been met.

The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices are only covered under certain medical indications.

The file shows that a pneumatic compression device identified by code E0652, and a segmental pneumatic appliance accessory (E0668) were requested. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that you have a medical history of a left humerus fracture which has lymphedema of the left upper extremity. There is no documentation that the Medicare coverage criteria for the requested pneumatic compression device and related accessory have been met. Provided medical records do not document that you have lymphedema extending onto the chest, trunk and/or abdomen on physical examination reports. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device and related accessory.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two additional home health visits.

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 medically necessary.

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 these services. Our reviewer says that the services are not medically necessary. 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 the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration beyond what was approved by the health plan. The enrollee has stable vital signs, does not require complex wound care, new enteral feedings, IV antibiotics or other skilled nursing need. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. Two further visits are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve two additional home health visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the consultation and testing to be provided by an OON provider.  You asked the Plan to pre-approve the consultation and testing. You say that you do not want to switch doctors.  The Plan denied your request. The Plan says the provider is out-of-network.  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 the consultation and testing to be provided by an OON provider.   Your complaint that you are unhappy with the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services or to require 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
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for surgical services provided to the enrollee on February 8, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care. We 
overturned the Plans denial as the case file lacked a Plan contract for review. The Plan requested a reopen and
provided a copy of the relevant Plan contract.
The Plan is correct in this case. 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 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 surgical services provided to the enrollee on February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve posterior four-unit fixed bridge replacing the lower right second molar (tooth #31) and the lower right third molar (tooth #32) with pontics (false teeth; procedure code D6240) using the lower right first bicuspid (tooth #28) and the lower right first molar (tooth #30) as abutments (anchors; procedure code D6750).

You asked the Plan to pre-approve these dental services. You say that the requested services are not a covered benefit. The Plan denied your request. The Plan says the requested services are not a covered benefit.

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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The requested pontic services are only covered for teeth 6-11 and 22-27. The requested crown is only covered for teeth 5-12 and 21-28. You are requesting pontics for teeth 28, 31, and 32 and crowns for tooth 30. These teeth are not covered for the services requested. Therefore, we decided that the Plan does not have to pre-approve posterior four-unit fixed bridge replacing the lower right second molar (tooth #31) and the lower right third molar (tooth #32) with pontics (false teeth; procedure code D6240) using the lower right first bicuspid (tooth #28) and the lower right first molar (tooth #30) as abutments (anchors; procedure code D6750).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Icosapent for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Icosapent for the enrollee.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.