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

 We decided that the Plan does not have to pre-approve Zarxio for chemotherapy-induced neutropenia.  You asked the Plan to pre-approve the Zarxio treatment. You say that this is a necessary treatment to combat side effects of chemotherapy. The Plan denied your request. The Plan says this is being provided in a clinical trial. Original Medicare pays for services related to clinical trials.  The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.  In this case, you asked the Plan to pre-approve the Zarxio treatment. This is to treat a side effect of chemotherapy. The trial protocols indicate that the chemotherapy is administered through the trial directly. As such, this is considered a routine cost of the trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Zarxio for chemotherapy-induced neutropenia.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the massage therapy services, and the acupuncture services received May 18, 2021 to July 13, 2021.  You asked the Plan to pay for the massage therapy services and the acupuncture services. You say that you had these services for lower back pain due to stroke. The Plan denied your request. The Plan says the services received are not a covered benefit.  The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). You have been asked to pay $20 copayment for each of the first six acupuncture services received. You are then asked to pay the entire amount for the remainder of the acupuncture services received after the first six. 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 pay for the massage therapy services, and the acupuncture services received May 18, 2021 to July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home-delivered meal services.  You asked the Plan to pre-approve home-delivered meals. You say that you need this service. The Plan denied your request. The Plan says the claim was correctly denied.  Medicare generally does not cover home-delivered meals. However, the Plan offers a supplemental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a benefit in excess of Medicare coverage, the file does not show that you were discharged from an inpatient stay with a qualifying diagnosis of congestive heart failure. Therefore, we decided that the Plan does not have to pre-approve home-delivered meal services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a raised toilet seat with handles.  You asked the Plan to pre-approve a raised toilet seat with handles. You say that a raised toilet seat with handles is medically necessary. The Plan denied your request. The Plan says this item is not covered by Medicare.  The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat 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 raised toilet seat with handles.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve chore and attendant care services  You asked the Plan to pre-approve the requested services. You say that the enrollee needs help managing daily living and routines. The Plan denied your request. The Plan says Medicare does not pay for custodial services.  The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered.   We looked at the file and Medicare rules. We find that the services at issue are considered custodial in nature. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve chore and attendant care services
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services provided June 2, 2021 to June 8, 2021 billed with DRG 286.  You asked the Plan to pay for the inpatient services billed with DRG 286. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with DRG 286. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient services billed with DRG 286. Our reviewer says that the documentation does not support that the DRG billed. Our physician reviewer found the enrollee was admitted from the emergency department with labored breathing and lower extremity swelling. The history and physical, stated the reason for admission was an acute congestive heart failure (CHF) exacerbation. No history of Coronary Artery Disease (CAD) was noted in the exam on admission. Cardiac catheterization on June 4, 2021 during this admission, resulted as mild diffuse CAD, with diffuse ectasia, for medical management. The CAD appears to have been diagnosed with this admission, but there was no treatment towards it, other than medication adjustments. The discharge summary stated the admission was for the acute CHF exacerbation with good effect of the diuresis. Therefore, the DRG billed (286) was not supported by the documentation.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services provided June 2, 2021 to June 8, 2021 billed with DRG 286.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Emgality.  You asked the Plan to pre-approve Emgality. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Emgality.   Benefits for Emgality 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0483) provided on February 10, 2021.  You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on February 10, 2021.
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. The Plan denied your request. The Plan says you do not have daily skilled nursing or therapy needs that can only be provided on an inpatient basis.  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 you presented to the acute care hospital with a small bowel obstruction with an internal hernia and perforated diverticulitis. There are no reported complications with the colostomy. You are walking at a supervision assist level and are at supervision for transfers. There are no reports from occupational therapy available. You do not require the services of a skilled professional nurse or qualified therapist to provide medically necessary treatment. You do not require daily skilled services on an inpatient basis in a SNF setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on August 6, 2021.  You asked the Plan to reimburse you an additional amount for eyeglasses. The Plan denied your request. The Plan says you have purchased your eyeglasses from an out-of-network provider, the benefit is only up to $90. The Plan says that your reimbursement was processed correctly, and your reimbursement check in the amount of $90 was sent out on September 2, 2021.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when you use a non-participating provider up to $90 reimbursement.  We looked at the file and the Plan's rules. The file shows that you have purchased your eyeglasses from an out-of-network provider and the benefit is only up to $90. Your reimbursement was processed correctly, and your reimbursement check in the amount of $90 was sent out on September 2, 2021. Therefore, we decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on August 6, 2021.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Keytruda.  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 that the services are not medically necessary.  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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has head and neck right maxillary sinus cancer. Keytruda at 400 mg intravenously every six weeks in combination with carboplatin and 5FU is considered a standard dose for a patient with head and neck cancer. The requested use is supported by the National Comprehensive Cancer Network (NCCN) guidelines. The services are reasonable and medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve Keytruda.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis.  You asked the Plan to pre-approve Eliquis. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.     Benefits for Eliquis 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve two core buildups, including any pins when required (D2950 x2), two pontics (D6240 x2), and two retainer crowns (D6750 x2).  You asked the Plan to pre-approve the core buildups, pontics, and retainer crowns. You say that you feel that these services should be reconsidered for coverage. The Plan denied your request. The Plan says these services are 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 two core buildups, including any pins when required (D2950 x2), two pontics (D6240 x2), and two retainer crowns (D6750 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the power seat elevation system (CPT code E2300), for the enrollee.  You asked the Plan to pre-approve the power seat elevation system. You say that the item is necessary. The Plan denied your request. The Plan says the item is not covered based on Medicare rules.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power seat elevation system have not been met. The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation system (CPT code E2300), for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the sleep study provided on April 5, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the sleep study. You say that you would like this service to be covered because you needed the sleep study so you did not lose your job. The Plan denied your request. The Plan says you received these services at an OON facility which was referred by another non-contracted provider. The Plan also says that no authorization was obtained to receive this service OON.  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. Therefore, we decided that the Plan does not have to pay for the sleep study provided on April 5, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Lidocaine 5% patches.  You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.  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 Lidocaine 5% patches.   Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chiropractic services provided on April 27, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on April 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the duplex scan of lower extremities rendered on June 28, 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. The rules say that claims must be billed with the most precise diagnosis code.  We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate primary diagnosis code. 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 duplex scan of lower extremities rendered on June 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Revlimid capsules.  You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.  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 Revlimid capsules.   Benefits for self-administered drug 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 long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH would provide no additional services.  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 provided 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 long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency care provided on October 14, 2021.  You asked the Plan to waive the copayment for emergency care. You say that you should not be responsible for the charges due to the quality of care you received. 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 $90 copayment for emergency care.   You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on October 14, 2021.  Your quality of care concerns have been handled separately by the Plan. Medicare does not permit Maximus to make a decision on this type of complaint.