Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 additional home health skilled nursing visits.
You asked the Plan to pre-approve 2 additional home health skilled nursing visits. You say that the 2 additional home health skilled nursing visits are medically necessary. The Plan denied your request. The Plan says the 2 additional home health skilled nursing visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 2 additional home health skilled nursing visits. Our reviewer says that the 2 additional home health skilled nursing visits are not medically necessary. Our physician reviewer found the documentation doesn't support that the member requires additional skilled nursing services to provide treatment that is medically necessary. The member does not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve the member's
condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. She has had an additional 10 nursing visits authorized for education and wound care. The requested additional 2 visits 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 2 additional home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 additional home health skilled nursing visits.
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 has cognitive deficits that require
redirection. The Plan denied your request. The Plan says the enrollee does not require daily skilled services 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 the most recent therapy documentation indicates the enrollee requires contact guard assistance for
ambulation with a rolling walker up to 100 feet and contact guard assistance with bed mobility and transfers.
The enrollee has stabilized medically and is ready for discharge from the hospital. The member does not
require skilled nursing or skilled therapy services on a daily basis. Although further rehabilitation services
would be appropriate to improve function, 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 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental health care provided on January 21, 2021, and February 11, 2021.
You asked the Plan to waive the copayments for outpatient mental health care. You say that you did not receive any services. 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 $20 copayment for each individual/group therapy visit with a psychiatrist and a $40 copayment for each individual/group therapy visit for outpatient mental health care. The medical records show that you received outpatient mental health care on January 21, 2021. The services were rendered by a behavioral health specialist. Therefore, you are responsible to pay the $40 copayment. The medical records show that you received outpatient mental health care on February 11, 2021. The services were rendered by a behavioral health specialist. Therefore, you are responsible to pay the $40 copayment. The total amount you owe is: $80. You have been asked to pay the total copayment amount of $80 for outpatient mental health care. Outpatient mental health care falls within the outpatient mental health 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 copayments for outpatient mental health care provided on January 21, 2021, and February 11, 2021.
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 the enrollee meets the criteria for and would benefit from the services provided at an LTACH. The Plan denied your request. The Plan says criteria for an LTACH have not been met, and the enrollee's medical needs are being met in the current acute setting. An LTACH would add no additional services. With additional time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.
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 LTACH services. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda and Mvasi for the enrollee.
You asked the Plan to pre-approve Keytruda and Mvasi. You say that the member will not likely respond to FDA approved alkylating agents and Optune is contraindicated. The Plan denied your request. The Plan says that the drug/regimen is not being prescribed for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda and Mvasi. Our reviewer says that Keytruda and Mvasi are not medically reasonable and necessary for the enrollee in this case. Keytruda and Mvasi are not FDA-approved for the enrollee's diagnosis. The use of Keytruda and Mvasi is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Keytruda and Mvasi. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda and Mvasi have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda and Mvasi for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on June 1, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and paid. You say that these services are provided in good-faith for reimbursement. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that the member's primary care physician did not refer these services.
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 skilled nursing services provided on June 1, 2020 by an out-of-network (OON) provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from February 20, 2021, to March 16, 2021.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from November 5, 2020, to February 19, 2021. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from February 20, 2021, to March 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency ambulance transport (A0427) provided on February 5, 2021.
You asked the Plan to pay for the emergency ambulance transport. You say that four men from two different companies arrived after your husband called 911. You also say that the paramedics stated they came because you were on a blood thinner but did not transport you. The Plan denied your request. The Plan says your plan covers ambulance transportation only when you are actually transported by ambulance. The Plan also says that since you were not transported by this ambulance, the service is not covered under your plan.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the emergency ambulance transport (A0427) provided on February 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for a subsequent nursing facility care visit (99308) provided on June 16, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for a nursing facility care visit. You say that you have rendered treatment in good faith. You also say that the service was provided with no adequate time frame to obtain authorization for the service. The Plan denied your request. The Plan says services should be received from network providers who are listed in the provider directory, except when urgent or an emergency.
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a subsequent nursing facility care visit (99308) provided on June 16, 2020, by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ophthalmology office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you had eye surgery a few years ago and you would like to follow up with the doctor that did the eye surgery. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 ophthalmology office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift mechanism (E0627) with sales tax (S9999) and delivery fee (A9901) provided on February 1, 2021, by a supplier not enrolled in the Medicare program.
You asked the Plan to pay for a seat lift mechanism with sales tax and delivery fee. You say that you were never told your purchase had to be in-network. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism (E0627) with sales tax (S9999) and delivery fee (A9901) provided on February 1, 2021, by a supplier not enrolled in the Medicare program.
Your complaint about not being given proper instruction on how to purchase the items at issue infao this case is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam provided by an out-of-network provider on
May 26, 2021.

You asked the Plan to pay for the eye exam. You say that you have been seeing these people for at least two
years and were not informed the doctor was not part of the plan. The Plan denied your request. The Plan says
the claim was not paid because the service was performed by a doctor who is not in your plan and prior
approval was not received.

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 eye exam provided by an out-of-network
provider on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for optometry services provided on June 25, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for optometry services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
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 optometry services provided on June 25, 2020 by an out-of-network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the enrollee was recently diagnosed with osteoporosis. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our reviewer says that Prolia (J0897) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee has not tried and failed the required drug, Zoledronic Acid. Our reviewer found that there is no indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer also found that based on the medical records provided the enrollee has not had an osteoporotic fracture. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Q6 Edge 3 Power Wheelchair, code K0861,
and accessories for the enrollee.
You asked the Plan to provide for a K0861 Group 3 Power wheelchair and accessories. You say that the
requested power wheelchair and accessories are medically necessary for the enrollee. The Plan denied your
request. The Plan states the enrollee meets the criteria for a Group 3 Power wheelchair but not a Group 3 Power
wheelchair coded as K0861. Maximus partially overturned the Plans denial. The Plan requested a reopen and
provided additional information. The Plan states the enrollee meets criteria for a Group 3 power wheelchair,
however, does not meet criteria for tilt and recline features, which Maximus confirmed. The Plan also noted the enrollee
does not meet the weight capacity required for a K0861 power wheelchair.
The Plan is correct in this case. Based on the medical records provided, the enrollees weight at the time of the evaluation
was 180 pounds. The enrollee is clearly well under the minimum weight requirement (285 to 400 pounds) for a K0861
power wheelchair. Therefore, we decided that the Plan does not have to provide coverage for a Q6 Edge 3 Power
Wheelchair, code K0861, and accessories for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on November 11, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because you were transferred to a nearby hospital due to the coronavirus and were not in medical distress. 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 $250 copayment for ambulance services. You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the ambulance services 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 ambulance services provided on November 11, 2020.