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

 We decided that the Plan does not have to pre-approve a lightweight portable motorized/power wheelchair.  You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the requested provider does not participate in Medicare.  The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program.  The requested provider is not eligible to bill Medicare. Personal Choice did not pre-approve the wheelchair. We found no exception that would require Personal Choice to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a lightweight portable motorized/power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the injection procedure provided at an outpatient hospital facility on March 10, 2021.  You asked the Plan to waive the copayment for the injection procedure. You say that you were advised to go to the hospital for this injection.  You also said that this same service was provided in November of 2020 and there was no copayment at that time. The Plan denied your request. The Plan says this copayment was charged correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $100 copayment for services in an outpatient hospital.   The enrollee has been asked to pay a $100 copayment for the injection procedure. The injection procedure falls within the services in an outpatient hospital benefit category. This copayment applies regardless of what may have been charged in previous years. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the injection procedure provided at an outpatient hospital facility on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the urgent care services you received on 
July 9, 2021. 
 
You asked the Plan to waive the copayment for the urgent care services. You say that you went to the urgent 
care and paid a copayment.  You were told that you needed to go to the emergency room.  You don't think you 
should have to pay a copayment for both of these. The Plan denied your request. The Plan says you were 
charged this copayment correctly. 
 
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 $40 
copayment for urgent care.  
 
 You have been asked to pay a $40 copayment for the urgent care services. This copayment applies even if you 
end up going to the emergency room later. 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 urgent 
care services you received on July 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you need skilled care to return to your prior level of function. 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 the 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 skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve seven additional home health physical therapy visits for 
the enrollee. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not support the need for a skilled physical therapist to make more home 
visits at this time. 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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the documentation 
does not support that the enrollee requires additional skilled rehabilitation services to effectively provide 
treatment, care, and/or services to provide treatment that is medically necessary. The enrollee does not require 
additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve the 
enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent 
deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical 
problems or hospitalizations. The enrollee and the caregivers should be independent with a home exercise 
program. The requested home health services are 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve seven additional home health physical therapy visits for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided the Plan does not have to pay for cardiovascular risk assessment testing.  
 You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says this testing is not covered as a screening. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests are not covered by Medicare. The 
testing at issue was requested solely for screening purposes. Therefore, we decided that the Plan does not have 
to pay for cardiovascular risk assessment testing provided to the enrollee on September 16, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from July 17, 2020, through August 6, 2020, billed with code KAKF1.

You asked the Plan to pay for the SNF services as billed. You say that it is felt that the MDS form is correct as the functional scores were obtained from the various assessments throughout the three-day assessment period. The Plan denied your request. The Plan says that the nursing and functional assessments included cannot be used to support the scores on the MDS form since they are not documented in each assessment exactly as they should appear on the form.

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 Plan has not provided a valid, verifiable denial rationale in this case. The Plan states that the usual functional ability information is not supported as the various assessments performed over the three-day assessment period are not defined on the required six-point scale. However, based on the rules, the information that is entered into Section GG is not assigned to this six-point scale until the staff member completes the form. These functional scores are assigned based on a review of multiple reports from the three-day assessment period. There is no need for these to be expressed in the records using this scale, as this is a scale for the MDS assessment only. 

The Plan has not identified a specific issue in which it is felt that the reported functional score is not supported by the records. Maximus is not able to independently review these levels when the Plan has not made a specific allegation regarding which functional score is deemed to be incorrect. We find that the scores recorded appear to match the functional levels in the various assessments. Without a valid denial rationale, we find that the Plan's determination in this case is not supported. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from July 17, 2020, through August 6, 2020, billed with code KAKF1.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laser surgery to treat psoriasis provided to the enrollee on 
July 6, 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 this surgery was cosmetic and is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   The records show the laser treatments were for psoriasis. The enrollee did not have prior authorization for these 
services. These services were cosmetic in nature. Therefore, we decided that the Plan does not have to pay for 
laser surgery to treat psoriasis provided to the enrollee on July 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Intracept procedure is 
considered experimental for low back pain. More research is needed to show its safety and efficacy. The 
services are therefore 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 an Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Methotrexate 2.5mg tablets. 
 You asked the Plan to pre-approve the Methotrexate 2.5mg tab. You say that Methotrexate is medically 
necessary. The Plan denied your request. The Plan says Methotrexate 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 Methotrexate 2.5mg tablets. Benefits for the 
Methotrexate 2.5mg tab 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 waive the copayment for the diagnostic eye exam (92014) provided on June 4, 2021.

You asked the Plan to waive the copayment for the diagnostic eye exam. You say that the services should be covered as you are dissatisfied with the way it was handled by the provider. The Plan denied your request. The Plan says the cost sharing applied correctly based on the services rendered.

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 $40 copayment for Vision care. 

You have been asked to pay a $40 copayment for a diagnostic eye exam. The record shows that the provider is an ophthalmology specialist, and you were diagnosed with cataracts (H25.813). The exam for management of cataracts falls into the Vision care 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 diagnostic eye exam (92014) provided on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient office visits (99202, 99212) and unlisted 
evaluation and management service (99499) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient services. You say that the closest in-network provider is 47.5 
miles away while this provider is less than 2 miles away. The Plan denied your request. The Plan says 
enrollee's must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 outpatient office visits (99202, 99212) 
and unlisted evaluation and management service (99499) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the preferred products for the plan are Orthovisc, Synvisc, and Synvisc-One. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not 
trialed viscosupplemental treatments such as Orthovisc, Synvisc, and Synvisc-One. Step therapy, as outlined by 
the plan, requires that these be trialed first. The documentation does not outline contraindications or reasons 
these medications were not considered or that the plan?s additional required drugs would likely be less effective 
and/or likely have adverse effects for the enrollee. Without the support of the documentation, Gel-One is not 
approved, as step criteria have not been met. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on September 30, 2020, 
through October 8, 2020 at the 872 diagnosis related group (DRG) rate. 
 You asked the Plan to pay for the inpatient hospital services at the DRG 872 rate. You say that you would like 
reconsideration based on the documentation submitted. The Plan denied your request. The Plan says DRG 872 
is not supported by the records submitted. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 In this case, you billed the inpatient services provided with A41.51. 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 inpatient hospital services at the DRG 872 rate. Our reviewer says that the 
documentation was inconsistent/unclear regarding a diagnosis of Sepsis. Supporting medical record 
documentation was not found within the record. Our physician reviewer found there was no evidence of a 
sepsis. The review has determined that the documentation did not support a primary diagnosis of sepsis due to 
Escherichia Coli.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 30, 2020, through October 8, 2020 at the 872 diagnosis 
related group (DRG) rate.
Appeal type: Testing
Decision: Favorable

 We decided that the Plan has to reduce the cost-sharing charges for ultrasounds provided on April 25, 2018, 
and February 6, 2019. 
 You asked the Plan to reduce the cost-sharing charges for ultrasounds. You say that you should only owe a $20 
copayment. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms 
how much you should expect to pay for ultrasounds provided in 2018.  
 We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 20% 
coinsurance for ultrasounds provided in 2018. The Plan contract does not clearly say how much enrollees must 
pay for ultrasounds provided in 2018. Therefore, the Plan must waive the amount of $39.58 for an ultrasound 
provided on April 25, 2018.  
 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 enrollees must pay a $20 copayment for basic imaging services provided in 
2018.   
 The Plan says you must pay 20% coinsurance for ultrasounds provided in 2019. Based on the Plan contract, 
however, you cannot be asked to pay more than a $20 copayment for basic imaging services, including 
ultrasounds. Therefore, we decided that the Plan has to reduce the cost-sharing charges for an ultrasound 
provided on February 6, 2019, from $45.49 to $20.  
 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Methyprednisolone. 
 You asked the Plan to pre-approve Methyprednisolone. You say that this is medically necessary. The Plan 
denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's 
prescription drug plan. 
 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 Methyprednisolone.  
 Benefits for Methyprednisolone 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Tirosint 137mcg capsules. 
 You asked the Plan to pre-approve Tirosint. You say that Tirosint is medically necessary. The Plan denied your 
request. The Plan says Tirosint 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 Tirosint 137mcg capsules.  
 Benefits for Tirosint may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.