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

We decided that the Plan does not have to pre-approve Ofev.

You asked the Plan to pre-approve Ofev. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

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 Ofev.

Benefits for Ofev 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not need an intensive team to oversee your 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 with your current medical stability, and no medical complexity, there is no need for rehabilitation physician supervision 3 times per week. You are at a modified independent assist level for bed mobility and transfers, supervision for ambulation, moderate assist for lower body dressing, and standby assist for toileting. At the current functional level, you do not require intensive therapies, consisting of at least 3 hours of therapy per day.

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: 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 you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from continued physical therapy, and occupational therapy, your rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility or in home with therapies. 

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endodontic therapy (D3310).
You asked the Plan to pre-approve the endodontic therapy. The Plan denied your request. The Plan says this service is not covered.
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. Therefore, we decided that the Plan does not have to pre-approve an endodontic therapy (D3310).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer.

You asked the Plan to pre-approve a Superion interspinous spacer. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 a Superion interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not include the primary source documentation of a recent magnetic resonance imaging (MRI) to assess the extent of the lumbar disease. The elements of the coverage criteria 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 a Superion interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion interspinous spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve negative pressure wound therapy (NPWT) electrical pump (E2402) and wound care set for negative pressure wound therapy electrical pump, includes all supplies and accessories (A6550).

You asked the Plan to pre-approve the negative pressure wound therapy pump and supplies. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the records show that you have been using the NPWT device for more than 4 months.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. In this case, you have requested 2 additional months of wound VAC therapy. The records show that the Plan had approved 5 months of wound VAC therapy. Medicare rules say that a NPWT pump and supplies will be denied as not reasonable and necessary when used for more than 4 months on the most recent wound. Based on this information, we decided that Medicare rules for coverage of the negative pressure wound therapy pump and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve negative pressure wound therapy (NPWT) electrical pump (E2402) and wound care set for negative pressure wound therapy electrical pump, includes all supplies and accessories (A6550).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the periodontal scaling and root planing - four or more teeth per quadrant (D4341), bone replacement graft - retained natural tooth - first site in quadrant (D4263), guided tissue regeneration - resorbable barrier, per site (D4266), surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment - includes placement (D6057), abutment supported porcelain fused to metal crown (high noble metal) (D6059), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), and osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant (D4260).

You asked the Plan to pre-approve the periodontal scaling and root planing, bone replacement graft, guided tissue regeneration, endosteal implant, custom abutment, abutment supported crown, tooth extraction and osseous surgery. You say that you would like these services covered. The Plan denied your request. The Plan says these services are not covered under your benefits.

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. Therefore, we decided that the Plan does not have to pre-approve the periodontal scaling and root planing - four or more teeth per quadrant (D4341), bone replacement graft - retained natural tooth - first site in quadrant (D4263), guided tissue regeneration - resorbable barrier, per site (D4266), surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment - includes placement (D6057), abutment supported porcelain fused to metal crown (high noble metal) (D6059), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), and osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant (D4260).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on July 21, 2021.

You asked the Plan to waive the copayment for arthrocentesis. You say that you disagree with the charges because you thought that you would only owe a $40 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You have been asked to pay a $350 copayment for arthrocentesis. Arthrocentesis falls within the outpatient surgery, including 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 arthrocentesis provided on July 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).  

You asked the Plan to pre-approve a Freestyle Libre CGM. You say that you need this. The Plan denied your request. The Plan says the requirements 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 use insulin with at least three daily administrations, 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 assess 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 Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 23, 2021.  

You asked the Plan to pay for oral evaluation. You say that you did not receive this service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because dental code D0140 is covered once per plan year and you already received this service on February 1, 2021.  

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 oral evaluation D0140 once per plan year.   

We looked at the file, the Plan's rules, and Medicare rules. You previously received a D0140 examination on February 1, 2021, so the benefit for this service is exhausted. Based on this information, we decided that the Plan's rules for coverage of oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a core buildup (D2950) for tooth #19.  

You asked the Plan to pre-approve the core buildup. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not covered by your dental 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. Therefore, we decided that the Plan does not have to pre-approve a core buildup (D2950) for tooth #19.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance services provided on July 16, 2021.

You asked the Plan to pay for ambulance services. You say that you agree that this charge seems high and hope the Plan will reconsider it. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because ambulance supplies are included in the base payment rate for ambulance transportation and are not separately paid.

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 did not submit an Explanation of Benefits (EOB) or claim form for the claim at issue. The Plan says that they have denied payment for a non-covered ambulance supply charge. Without a copy of the EOB or claim form for this claim, we cannot determine whether the ambulance provider billed a non-covered charge for which you might be responsible. Therefore, the Plan has not shown that its decision to deny payment is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for ambulance services provided on July 16, 2021.

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seven home skilled nursing visits.

You asked the Plan to pre-approve the visits. You say that this should be reconsidered as the visits are medically necessary. The Plan denied your request. The Plan says this is 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 the visits. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found that in this case, the documentation does not support you require additional skilled nursing services or to provide treatment that is medically necessary. You do not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve seven home skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for brand specific CPAP supplies.

You asked the Plan to provide coverage for brand specific CPAP supplies. You say that you prefer to use the
requested brand of supplies. The Plan denied your request. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information. The Plan states that this brand of supplies is not
covered based on the 2021 durable medical equipment brand list provided in the Plan contract. In addition, the
Plan states they did not receive a statement from your physician indicating there are special circumstances or a
medical condition which requires you so use this brand. The Plan also notes the brand listed by Maximus to be
included in or qualify is only available for enrollees in a specific durable medical equipment network and you
are not in that network.

We reviewed the Plan contract and the medial records. The Plan is correct in this case. Medicare rules say that
plans can require enrollees to get durable medical equipment from specific network providers or use specific
brands covered by the Plan contract. The brand requested is not covered by your Plan contract. Your physician
did not provide documentation that the brands offered by the Plan were not appropriate for your use. Therefore,
we decided that the Plan does not have to provide coverage for brand specific CPAP supplies.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography scan with quantitative calcium
scoring.
You asked the Plan to pre-approve this testing. You say that when this was appealed, this imaging was and
testing medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not
met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that the records specifically state
the calcium scoring was ordered by the physician as a screening and not a diagnostic test. The Plan states that
quantitative calcium scoring is not a covered service and will be denied as not medically necessary.
The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed in
the Medicare rules section, are not covered. The test at issue in this appeal, calcium scoring, was requested
solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we
decided that the Plan does not have to provide coverage for a computed tomography scan with quantitative
calcium scoring.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.
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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as of December 25, 2021, the member did not require any skilled nursing or rehabilitation services on a daily basis. He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of December 25, 2021. The member did not have any parental medications, complex wound care or nutrition given via a feeding tube. The member received skilled care and improved; however, his function had plateaued by December 25, 2021 and he did not require any further inpatient skilled rehabilitation services. The member's function was at or near his prior level of function and he could be discharged to a lower level of care for further services. As of December 25, 2021, the member required custodial 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 20, 2021.

You asked the Plan to pay for the services. You say that this testing is not available through any other laboratory. The Plan denied your request. The Plan says the rendering provider is not participating.

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 laboratory services provided to the enrollee on April 20, 2021.