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

We decided that the Plan does not have to pre-approve the handheld shower hose (E1399).
You asked the Plan to pre-approve the handheld shower hose. You say that you have already been approved for a shower chair, bathtub rails and other bathroom items. This is very much necessary for you. The Plan denied your request. The Plan says this is a hygienic item and is not covered.
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 the handheld shower hose (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bathtub transfer rail.

You asked the Plan to pre-approve a bathtub transfer rail. You say that bathtub transfer rail is medically necessary. The Plan denied your request. The Plan says bathtub transfer rail is not covered by Medicare.

The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While this item may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a bathtub transfer rail.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the professional component for a CT scan provided on July 21, 2021.
You asked the Plan to waive the copayment for the professional component of a CT scan. You say that you disagree with the $50 charge and the fact the Plan paid so much less. 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 $50 copayment for specialist services. You have been asked to pay a $50 copayment for the professional component of a CT scan. The professional component of a CT scan falls within the physician/practitioner services, including doctor's office visits benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the professional component for a CT scan provided on July 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a compression sleeve (A6549).
You asked the Plan to pre-approve a compression sleeve. You say that a compression sleeve is medically necessary for lymphedema. The Plan denied your request. The Plan says a compression sleeve is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they are statutorily excluded. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a compression sleeve (A6549).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0428) provided on March 24, 2020.
You asked the Plan to waive the copayment for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 she must pay a $80 copayment for each Medicare-covered one-way trip via ground ambulance. The enrollee has been asked to pay a $80 copayment for the Medicare-covered one-way trip via ground ambulance provided. This means that the enrollee has been asked to pay the correct amount based on her contract with the Plan. This cost sharing is a contractual obligation she agreed to pay when she enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transportation (A0428) provided on March 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the enrollee's condition can be managed in an outpatient setting.
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 home health services. Our physician reviewer found that the enrollee can ambulate with supervision, is independent for upper body dressing, and is at supervision for lower body dressing. His oral hygiene, eating, toileting hygiene are at set up level, and showering/bating is at supervision. 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 prevent deterioration. The enrollee does not have complex wound care or new enteral feedings. The enrollee has had prior skilled nursing, and should be educated in disease management. 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, to establish a maintenance program, or to prevent deterioration. The enrollee's functional level does not require the skilled professional services of home health physical therapy. As the request for skilled nursing or skilled therapy is not medically necessary, the request for home health aide and social work services is not medically necessary for the enrollee's condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on September 25, 2019.
You asked the Plan to pay for the subsequent nursing facility care services. You say that the enrollee was seen for conditions unrelated to the hospice care and terminal illness. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care services provided on September 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
You asked the Plan to pre-approve a CGM and supplies. You say that you are going into surgery soon and will need to monitor your sugar levels in order to avoid rescheduling your surgery. The Plan denied your request. The Plan says that you do not meet coverage criteria.
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 and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostate artery embolization.

You asked the Plan to pre-approve prostate artery embolization. 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 prostate artery embolization. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic benign prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and efficacy. The most recent American Urological Association (AUA) guidelines do not recommend this procedure outside of a clinical trial 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 prostate artery embolization have not been met. Therefore, we decided that the Plan does not have to pre-approve prostate artery embolization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

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 criteria for coverage are not 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 you do not treat with insulin three or more times per day. The file shows that you take a fixed dose of insulin once per day. 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 a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care provided on September 13, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the wound care. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the wound care provided on September 13, 2021, by an out-of-network (OON) provider.
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 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 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 based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you are not able to go to the restroom, you are not
able to walk, and you are not able to do the things you need to on a day-to-day basis to live. The Plan denied
your request. The Plan says your records do not show you do not require skilled nursing services or skilled
rehabilitation services on a daily basis, and which can only be provided on an inpatient basis in a SNF. The
Plan states your rehabilitation and medical needs can be met with part-time skilled services in a lower level of
care, such as home with supervision and home health services. Home health services will need to be
approved by your health plan. The Plan states your rehabilitation needs can safely be received at a different
setting, for example, home with home health, in residential care, or home with close follow-up with your
doctor.
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 qualify for SNF coverage. You do
not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are
ambulating household distances. Daily skilled services are not shown to be required to establish a maintenance
program or to prevent deterioration of your condition. Your care needs, as a practical matter, can 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement power wheelchair (K0824).
You asked the Plan to pre-approve the replacement power wheelchair. You say that your current power wheelchair malfunctions and you need a replacement. The Plan denied your request. The Plan says the enrollee was provided with a power wheelchair March 3, 2021. The malfunctioning battery was repaired, and the existing unit meets the enrollee's needs.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a power wheelchair. The replacement power wheelchair serves the same purpose as the existing power wheelchair. Therefore, we decided that the Plan does not have to pre-approve a replacement power wheelchair (K0824).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a push manual wheelchair and accessories for the enrollee under the Medicare benefit.
You asked the Plan to pre-approve a push manual wheelchair and accessories. You say that a push manual wheelchair and accessories is medically necessary. The Plan denied your request. The Plan says the enrollee lives in a facility and therefore, this equipment is not covered by Medicare. The Plan suggested the appeal should be submitted under the enrollees Medicaid benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. The records show that a push manual wheelchair and accessories is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a push manual wheelchair and accessories for the enrollee under the Medicare benefit. It should be noted that Maximus does not have jurisdiction over Medicaid benefits. Please contact the Plan for further instruction on submitting this request to the holder of the enrollee's Medicaid coverage.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network physician services.

You asked the Plan to pre-approve out of network services. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says this provider is not a plan network 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 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 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 out of network physician services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist evaluation provided on
August 11, 2021.
You asked the Plan to waive the copayment for specialist evaluation. You say that the services should be
covered as you were never seen by a dr. The Plan denied your request. The Plan says the cost sharing applied
correctly based on the services provided.
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 $35
copayment for outpatient hospital services.
You have been asked to pay a $35 copayment for a specialist evaluation. The record indicates that you were
seen by a specialist while receiving outpatient hospital services. Specialist visits fall within the
Physician/Practitioner services, including doctor's office visits. 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 specialist evaluation provided on August 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardigram (EKG) you had on May 14, 2021.

You asked the Plan to waive the copayment for the EKG. You say that you had this test within 30 days of your surgery. You said that since the surgery was approved, this should be covered at no cost to you. 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 $20 copayment for non-radiological diagnostic services. 

You have been asked to pay a $20 copayment for the EKG. The EKG falls within the non-radiological diagnostic services benefit category. This copayment applies regardless of the reason for the test. 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 electrocardigram (EKG) you had on May 14, 2021.