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

We decided that the Plan does not have to pre-approve an auricular stimulator device (L8679, 64555).
You asked the Plan to pre-approve the stimulator device. You say that the service is medically necessary. The Plan denied your request. The Plan says the requested device is non-covered.
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulation will be denied as non-covered. We looked at the file and Medicare rules. The requested nerve stimulation device is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the stimulator device have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular stimulator device (L8679, 64555).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services rendered on May 17, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the service are not separately payable.

The Plan must follow Medicare rules. The rules say that all items and nonphysician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 

We looked at the file and Medicare rules. The file shows that the services at issue were rendered while the enrollee was under inpatient status and should be billed through the hospital. 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 the medical services rendered on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dermatology services from an out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you have experience with this provider. The Plan denied your request. The Plan says the services are available from network providers.
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 dermatology services from an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 24, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig.
You asked the Plan to pre-approve these services. You say that you are undergoing chemotherapy and losing your hair. The Plan denied your request. The Plan says the services are not a covered benefit.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the enrollee is too weak to be discharged home. The Plan denied your request. The Plan says there are no daily skilled nursing or therapy service needs.
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 services. Our physician reviewer found that the enrollee is medically stable without any acute exacerbations of chronic medical problems. The enrollee is not expected to make measurable gains within a reasonable and predictable period of time. She does not require skilled therapy to prevent deterioration with mobility or activities of daily living. She does not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, she does not require any skilled services on an inpatient basis, at a SNF 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for venipuncture services provided to the enrollee on October 23, 2020.

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says the rendering provider is a non-participating 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 venipuncture services provided to the enrollee on October 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gemtesa.

You asked the Plan to pre-approve Gemtesa. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.

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 Gemtesa.

Benefits for Gemtesa 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from July 6, 2021, through
July 31, 2021.
You asked the Plan to pay for the SNF services. You say that the SNF services were medically necessary. The
Plan denied your request. The Plan says the SNF services were not medically necessary.
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 pay for the SNF services. Our reviewer says that
daily skilled services are not medically necessary. Our physician reviewer found that at the time of discharge
from the hospital, the enrollee had stabilized medically. The enrollee did not require any skilled nursing or
rehabilitation services on a daily basis at an inpatient level of care. 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 enrollee did not require skilled therapy to establish a safe and
effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an
inpatient basis, at a SNF level of care at the time of discharge from the hospital. The enrollee did not have any
parental medication, complex wound care or nutrition given via a feeding tube. He was medically stable
without any acute exacerbations of chronic medical problems. His physical function was at or near his baseline
and he could have received further services 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 the SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for SNF services provided from July 6, 2021, through July 31, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for Freestyle Libre 14-Day Sensor, for the enrollee.

You asked the Plan to provide coverage for a Freestyle Libre 14-Day Sensor. You say that a Freestyle Libre
14-Day Sensor is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria
are not met. Maximus overturned the Plans denial stating the requested device would be beneficial.

The Plan requested a reopen and stated that the medical records do not document that the enrollee is testing
four or more times a day.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for this type of equipment, and it is required that all the criteria listed by Medicare are met. Based on the
medical records provided, all the required criteria are not met. We decided that Medicare rules for coverage of
Freestyle Libre 14-Day Sensor have not been met. Therefore, we decided that the Plan does not have to provide
coverage for Freestyle Libre 14-Day Sensor, for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on May 6, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that the fire department, not the ambulance company, transported you. You said that the ambulance company didn't perform any services, they only road alongside the ambulance that transported you. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan obtained records showing that you were transferred by the ambulance company from one hospital to another and that you signed an acknowledgement of this at 4:17pm on the date of service.

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 $225 copayment for ambulance services. 

You have been asked to pay a $225 copayment for the ambulance services. 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 ambulance services you received on May 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 home health skilled nursing visits.

You asked the Plan to pre-approve 5 home health skilled nursing visits. 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 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 5 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation does not support that the enrollee requires additional skilled nursing services to provide treatment that is medically necessary. The enrollee does not require additional skilled nursing 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 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 5 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 home health skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network spinal surgery. You say that the services are medically necessary. The Plan denied your request. The Plan says the out-of-network services are not emergent or pre-approved. There are network providers available.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve spinal surgery to be provided by an out-of-network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (POV) described by code K0806.

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 covered.

The Plan must follow Medicare rules. Medicare rules say that Group 2 POVs are denied as not medically necessary.

We looked at 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 a Group 2 power operated vehicle (POV) described by code K0806.
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 an intensive, complex, multidisciplinary approach to daily therapy. While you may benefit from physical therapy and occupational therapy, your rehab needs can be safely met in an alternate and low intensity setting such as a skilled nursing facility. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
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 laboratory services provided on June 17, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that you believe that you require this level of care. The Plan denied your request. The Plan says you do not require daily skilled services.
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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member is a female with a past medical history including heart disease, diabetes mellitus, hypertension, and chronic lung disease requiring home oxygen therapy who was admitted to an acute hospital with a chronic obstructive pulmonary disease (COPD) exacerbation. She has been treated medically and stabilized. The member has stabilized medically and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).
You asked the Plan to pre-approve the special supplemental benefits for the chronically ill. You say that you need these services for your chronic conditions. The Plan denied your request. The Plan says you do not meet the required criteria that makes you eligible for these benefits.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the special supplemental benefits for the chronically ill have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the Velcade injection you received on April 9, 2021.
You asked the Plan to waive the cost sharing for the Velcade injection. You say that you have met your cost share maximum for Medicaid for the month of April. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that the $100 administration charge that you were assessed for this date of service has been waived, so the only cost sharing for this date relates to the drug itself. The Plan says that it contacted the hospital on your behalf to see if they had your Medicaid information on file. They advised that they did and they submitted this to Medicaid as well. Medicaid advised that you had not met your share criteria and the hospital stated that you were advised of this several times.
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% coinsurance for chemotherapy drugs. You have been asked to pay 20% coinsurance for the Velcade injection. The Velcade injection falls within the chemotherapy drugs 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. You may contact your Medicaid agency if you have questions regarding Medicaid cost sharing amounts. Therefore, we decided that the Plan does not have to waive the cost sharing for the Velcade injection you received on April 9, 2021.