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

We decided that the Plan has to pre-approve the requested blepharoplasty procedure.

You asked the Plan to pre-approve the blepharoplasty procedure with the requested providers. You say that this should be covered. The Plan denied your request. The Plan says that either the surgical center or surgeon is not in-network with the Plan. As such, the enrollee will need to see a different provider to have this surgery covered.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules says that out of network services must be arranged when network providers are not available. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There is conflicting information regarding the network status of the requested physician and the requested surgical center in this case. The original file states that the surgical center/group practice is in-network, while the surgeon is out of network. However, when Maximus requested clarification, the Plan responded that the surgeon is, in fact, a network provider. This was confirmed per a search of the provider directory on the Plan's website. The file shows that the enrollee consulted with the provider on October 14, 2021, after which the surgery was requested. The Plan then tried to re-direct the enrollee to a different provider. We find that since care was established with a network provider for this surgery, the Plan is required to cover the surgery at a location that the surgeon has privileges, regardless of network status of that location. We find that the denial is not supported based on the information submitted. Therefore, we decided that the Plan has to pre-approve the requested blepharoplasty procedure.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87798) provided on September 21, 2020.

You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed with an incorrect place of service.

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 11 for an office setting, but the record shows that the sample was taken in a nursing facility. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87798) provided on September 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional mileage for routine transportation trips.

You asked the Plan to provide coverage for additional mileage for routine transportation trips. The Plan denied your request. The Plan says your benefit covers 50 miles and your request is for an additional 26 miles, which exceeds your benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at your request, the records in the case file, and the rules. The file shows that the Plan covers 50 miles and your request is for an additional 26 miles, which exceeds your benefit limit. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide coverage for additional mileage for routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.

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 step therapy requirement is not met.

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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has right knee
osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do
not show that the required drugs would be contraindicated or less effective; therefore, Gel-One is not
reasonable or 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 not been met. Therefore, we decided that the Plan does not
have to pre-approve Gel-One.
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 in home with services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two core buildups, including any pins when required (D2950 x2), localized delivery of antimicrobial agents (D4381), periodontal maintenance (D4910), pontic (D6245), two retainer crowns (D6740 x2), surgical extraction (D7210), and adjunctive procedure (D9999).

You asked the Plan to pre-approve the core buildups, localized delivery of antimicrobial agents, periodontal maintenance, pontic, retainer crowns, surgical extraction, and adjunctive procedure. You say that you need to have surgery on your hip, and you cannot have any infections. You also say that you have one infection on your tooth and would like these services to be covered. The Plan denied your request. The Plan says these services are not covered benefits.

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), localized delivery of antimicrobial agents (D4381), periodontal maintenance (D4910), pontic (D6245), two retainer crowns (D6740 x2), surgical extraction (D7210), and adjunctive procedure (D9999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you need this denture because 
you are unable to eat. The Plan denied your request. The Plan says this service is allowed one time every 60 
months. The Plan also says that you had this service less than 60 months ago. 
 
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, maxillary partial denture is limited to 
one of either codes D5211, D5213, D5221, D5223, or D5225 once per 60 Months. The record shows that you 
received a maxillary partial denture (D5213) on May 15, 2019 and your maxillary partial denture benefit has 
been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture 
(D5213).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips (A0120). 
 
You asked the Plan to provide coverage for additional routine transportation trips. You say that you have 
dialysis three times a week and need additional transportation trips. The Plan denied your request. The Plan 
says you have exhausted your 2021 benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that you have used 48 
one-way transportation trips this year. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
provide coverage for additional routine transportation trips (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair (K0806). 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says your residence is not wheelchair accessible. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  

The item at issue in this appeal has added capabilities that are not needed for use in the home. Therefore, it is 
not considered medically reasonable or necessary by Medicare. Therefore, we decided that the Plan does not 
have to pre-approve a group 2 power wheelchair (K0806).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study to be provided by the requested out-of-network
provider.

You asked the Plan to pre-approve a sleep study. The Plan denied your request. The Plan says you must receive
care from in-network providers with the exception of emergency or urgent care, or if the care cannot be
provided with an in-network provider. There are in-network providers that can provide this service for you.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 a sleep
study to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for a patient of extreme age (99100) provided on
September 11, 2020.
You asked the Plan to pay for anesthesia for a patient of extreme age. You say that this is supported in the
records. The Plan denied your request. The Plan says this is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database
(MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment
for other services not specified.
We looked at the file and Medicare rules. Code 99100 has a status code of B, meaning its payment is bundled
into payment for other services. Based on this information, we decided that Medicare rules for coverage of
anesthesia for a patient of extreme age have not been met. Therefore, we decided that the Plan does not have to
pay for anesthesia for a patient of extreme age (99100) provided on September 11, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on March 31, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the service rendered to the 
enrollee was medically necessary. The Plan denied your request. The Plan says this service was referred and 
rendered by non-participating providers. The Plan also says that prior authorization was not 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. 
Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit provided on 
March 31, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mycophenolic acid (J7518).

You asked the Plan to pre-approve Mycophenolic acid. The Plan denied your request. The Plan says tier exceptions (co-pay reductions) are not available for drugs/devices covered by Part B.

The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. 

We looked at the file and Medicare Rules. Based on this information we decided that Medicare rules for a tier exception have not been met. Specifically, the drug at issue is being covered by the Plan under Medicare Part B. Part B Drugs are not eligible for tier exceptions. Therefore, we decided that the Plan does not have to pre-approve Mycophenolic acid (J7518).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration because this device would provide significant clinical and quality of life benefits for the member. The Plan denied your request. The Plan says the requested device is not medically necessary.
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 the Vertiflex Superion Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertilfex device is experimental. More research is needed to show its safety and efficacy. 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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zolpidem. 
 
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 self-administered drugs are not covered. 
 
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 Zolpidem.  
 
Benefits for these services 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 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on April 23, 
2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because 
this provider rendered medically necessary services. The Plan denied your request. The Plan says there was no 
documentation of consultation with the attending or primary care physician in the member's medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that for services rendered by a Clinical Psychologist 
(CP), you must attempt to consult the attending or primary care physician about provided services and 
document consent or declination date to consultations and date of consultations in patient's medical record. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the records do not indicate that the 
member's physician was consulted about the provided services. Of note, the submitted claim does not include a 
referring provider. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
(90832) provided on April 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the nasal endoscopy (31231) and hospital outpatient clinic 
visit (G0463) provided on June 17, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nasal endoscopy and hospital outpatient clinic visit. You say that you would 
like this claim to be reconsidered for payment based on medical necessity. The Plan denied your request. The 
Plan says these services were rendered by a non-participating provider. The Plan also says that these services 
were not authorized by the Plan. 
 
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 nasal endoscopy (31231) and hospital 
outpatient clinic visit (G0463) provided on June 17, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (84480, 84439, 85730, 80050, 82306) 
provided on May 22, 2020. 
 
You asked the Plan to pay for laboratory services. You say that you do not have access to patient information 
because the specimens are sent to your facility. The Plan denied your request. The Plan says these services 
were not billed with correct diagnoses. 
 
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 laboratory services have not been met. Therefore, we decided that 
the Plan does not have to pay for laboratory services (84480, 84439, 85730, 80050, 82306) provided on May 
22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.

You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically necessary. The Plan denied your request. The Plan says 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 the skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.