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

We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466) and the 
humidifier (CPT code E0562), for the enrollee. 
 
You asked the Plan to pre-approve the DME. You say that bilevel therapy would not be appropriate for you due 
to the severity of your chronic obstructive pulmonary disease (COPD). You state a home bilevel positive 
airway pressure (BiPAP) would be insufficient to address your ventilatory issues due to your COPD and 
chronic respiratory failure. You state you do require nocturnal and daytime volume ventilation to decrease the 
risk of respiratory failure. The Plan denied your request. The Plan says home mechanical ventilators are 
covered for neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to 
chronic obstructive pulmonary disease, none of which are documented. The Plan states the request for a home 
mechanical ventilator set in average volume assured pressure support (AVAPS) mode that could be delivered 
by BiPAP is not covered. The Plan states they would consider approval of E0471 upon request if required 
criteria are met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 DME. Our physician reviewer 
found a home ventilator is not medically necessary. This enrollee does not have neuromuscular disease or 
thoracic restrictive disease. The record indicates a diagnosis of COPD, but this is not supported by pulmonary 
function testing, which shows no evidence for obstructive lung disease. The FEV1 is above normal. The 
enrollee is morbidly obese and could have obesity-hypoventilation syndrome. But there is no arterial blood 
gases (ABG) showing carbon dioxide (CO2) retention. The enrollee does not have a coverable diagnosis. The 
enrollee does have hypoxemia, of uncertain cause. The denial of the home ventilator is upheld. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the home ventilator (CPT code E0466) and the humidifier (CPT code E0562), for the enrollee.
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 enrollee would benefit from intensive rehabilitation services to maximize their independence and plan for a safe discharge. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's needs can be met in a lower 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) provided on June 8, 2021, by an
OON provider.
You asked the Plan to pay for the office visit. You say that you were not aware you needed a referral. The Plan
denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON
provider.
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 the office visit (99204) provided on June 8, 2021,
by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 23, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that the service was received from an 
in-network provider. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $155 
copayment for radiological diagnostic services not including x-rays, performed by an in-network provider.  
 
The records show the Plan has covered your ultrasound; however, your coverage includes a cost sharing 
amount for which you are responsible. You have been asked to pay $142.31, which is less than the $155
copayment for an in-network ultrasound. Ultrasounds fall within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an ultrasound provided on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incomplete endodontic therapy (D3332) provided on June 7, 2021.

You asked the Plan to pay for the incomplete endodontic therapy. You say that you would like to appeal this service because of the information provided to you by the advocate you spoke with when you asked for your dental benefits. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

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 record shows that when you contacted the Plan on June 7, 2021 you inquired about plan benefits for a root canal, which is not the service you received. Therefore, we decided that the Plan does not have to pay for the incomplete endodontic therapy (D3332) provided on June 7, 2021.
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 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 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 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 not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. 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 you 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) and pulp vitality tests (D0460) provided on May 17, 2021.

You asked the Plan to pay for the cone beam CT capture and interpretation and pulp vitality tests. You say that you do not understand why these x-rays were denied, because you have x-ray coverage. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.

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 pay for the cone beam CT capture and interpretation (D0364) and pulp vitality tests (D0460) provided on May 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 27, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on July 9, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that you believe this should have been covered in full. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 the office visit (99213) provided on July 9, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Prostate specific antigen (PSA) (84153) provided June 2, 2020.
You asked the Plan to waive the copayment for the PSA test. You say that you received a bill for $20. You had a PSA (prostate specific antigen) test and should not have a copayment. The Plan denied your request. The Plan says the provider billed the claim with a diagnosis code indicating this was diagnostic and not a screening or preventive service. The claim was processed with correct copayment applied per the Evidence of Coverage.
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 copayment per visit for laboratory tests, non-radiological diagnostic tests, flat film x-rays and ultrasounds. You have been asked to pay $20 copayment for the PSA test. The PSA test falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for Prostate specific antigen (PSA) (84153) provided June 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower extremity prosthesis for use in the pool.

You asked the Plan to pre-approve a lower extremity prosthesis. You say that you need this item to help you
with balance and improve your ability to walk. The Plan denied your request. The Plan says the requested item
is considered to be equipment for exercise.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a lower extremity prosthesis for use in the pool.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the shoe inserts (A5500 and A5514).
You asked the Plan to pre-approve the shoe inserts. You say that the items are medically necessary. The Plan denied your request. The Plan says there are in-network providers available to provide these items.
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 shoe inserts (A5500 and A5514).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the magnetic resonance imaging (MRI) services provided on April 22, 2021.

You asked the Plan to waive the copay for the MRI. You say that the charge is unfair to people on a fixed income. The Plan denied your request. The Plan says the claim processed 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 $350 copay for diagnostic radiology. 

You have been asked to pay a $350 copay for the MRI. The MRI falls within the outpatient diagnostic tests 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 copay for the magnetic resonance imaging (MRI) services provided on April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device and appliances.

You asked the Plan to pay for intermittent limb compression device (E0651) and appliances (E0667). You say that the intermittent limb compression device was medically necessary. The Plan denied your request. The Plan says there is no documentation of a six-month trial of conservative therapy for chronic venous insufficiency nor documentation of venous stasis ulcers on physical exam.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 

The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device and appliances.
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 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 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 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 not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. 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 you 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm (J3590).
You asked the Plan to pre-approve Aduhelm. You say that the documentation supports that Aduhelm is medically necessary. The Plan denied your request. The Plan says Aduhelm is not medically reasonable and necessary for this enrollee.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Aduhelm. Our reviewer says that Aduhelm (J3590) is not medically reasonable and necessary for the enrollee. Our physician reviewer found Aduhelm is indicated for the treatment of Alzheimer's disease in patients with mild cognitive impairment or the mild dementia stage of the disease. There is no documentation of a Mini-Mental State Examination (MMSE) or other measures of cognition in this case. Our reviewer found that the documentation does not support that the enrollee has a diagnosis of mild cognitive impairment or the mild dementia stage of Alzheimer's disease. In addition, the magnetic resonance imaging in this case suggests the presence of cerebrovascular disease, which is evidence of a mixed etiology for the enrollee's symptoms. Our physician reviewer also found that the documentation does not support that Aduhelm is reasonably expected to be safe and effective for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm (J3590).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pelvic exam services provided on January 13, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan at no
charge. The Plan denied your request. The Plan says this benefit was exhausted at the time of service. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that this benefit was exhausted on January
8, 2020. The second exam provided on January 13, 2021 was less than the 24-month period between exams.
The records do not show you were at risk for cervical or vaginal cancer.
The Plan is correct in this case. Our physician reviewer found you have a diagnosis of atrophic vaginitis, for
which evaluation, counseling, and management was required. However, the records do not show you are at
high risk of cervical cancer and thus does not require a pap smear. Therefore, this visit did not qualify as a free
vaginal screening and was not within the timeframe required for a free vaginal screening. 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 pay for pelvic exam services provided on January 13, 2021.