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

We decided that the Plan does not have to pre-approve Soliris.

You asked the Plan to pre-approve Soliris. You say that the requested Soliris is medically necessary. The Plan denied your request. The Plan says the requested Soliris is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Soliris. Our reviewer says that the requested Soliris is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of myasthenia gravis. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The record does not indicate that meningococcal vaccination has been administered or that urgent therapy is indicated, and that meningococcal vaccine(s) will be administered as soon as possible to the enrollee provided with 2 weeks of antibacterial drug prophylaxis. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Soliris have not been met. Therefore, we decided that the Plan does not have to pre-approve Soliris.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that because covid-19 has brought financial hardship you do not eat at times to purchase pull ups. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $40 copayment charged, or vision services provided on
June 28, 2021.
You asked the Plan to waive this copayment. You say that you were told the first vision exam is free and this
copayment should be waived. The Plan denied your request. The Plan says this copayment was charged based
on the claim submitted by the provider and the Plan contract agreement. Maximus administratively overturned
the denial because the case file lacked the claim information the Plan based their decision on. The Plan
requested a reopen and provided the required claim information.
Based on the claim submitted by your provider, the Plan is correct in this case. Your provider did not bill this
as a routine eye exam. This claim was billed with code 92014, which is defined as a diagnostic vision exam.
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 $40
copayment for vision exam services. 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 $40 copayment charged, or vision services
provided on June 28, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for chiropractic manipulative treatment by an out-of-network provider on October 1, 2021.
You asked the Plan to pay for the chiropractic manipulative treatment. You say that the service was medically necessary. The Plan denied your request. The Plan says that no prior authorization was obtained.
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit the Evidence of Coverage. This means we cannot determine if the Plan's denial of non-emergent services is supported. Therefore, we decided that the Plan has to pay for chiropractic manipulative treatment by an out-of-network provider on October 1, 2021.
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: 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 is not medically necessary.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on October 23, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that you feel that there was an error made during the administration of your influenza and pneumonia shots that caused you to go to the ER. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 each emergency room visit. 

You have been asked to pay a $90 copayment for the ER visit. The ER visit 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 an emergency room (ER) visit provided on October 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 19 one-way routine transportation rides.
You asked the Plan to pre-approve the additional transportation . You say that you have chronic asthma and diabetes and this makes it difficult to travel. It is also bitter cold outside to have to wait outside for the bus. The Plan denied your request. The Plan says you have exhausted your non-emergent transportation benefit for 2022 as you have used all of the 12 covered visits.
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 12 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 all of your 12 trips January 5, 2022 through January 24, 2022. 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 pre-approve 19 one-way routine transportation rides.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with insulin three or more times per day. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0242U) rendered by the out-of-network (OON) provider on November 13, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis (0242U) rendered by the out-of-network (OON) provider on November 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on June 21, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says enrollees must use Medicare eligible providers to get their care and
services. Maximus overturned the Plans denial stating the contract was not clear regarding dental services and
Medical eligible provider. The Plan requested a reopen and stated that Maximus did not apply the contract
language correctly.
The Plan is correct in this case. 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.
The Plan contract is clear that enrollees must use Medicare eligible providers in general and also that non
covered out of network dental services would be the financial responsibility of the enrollee as well. Therefore,
we decided that the Plan does not have to pay for dental services provided on June 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (82274) rendered by the out-of-network (OON) provider on November 6, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (82274) rendered by the out-of-network (OON) provider on November 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related group (DRG) code 871.
You asked the Plan to pay for the inpatient hospital services billed with DRG 871. You say that that the enrollee demonstrated that the diagnosis of Sepsis was justified on admission presentation. The Plan denied your request. The Plan says that DRG 871 is not supported as the diagnosis of Pneumonia, unspecified.
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 principal diagnosis code J18.9, defined as Pneumonia, unspecified. 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 hospital services billed with DRG 871. Our reviewer says that the submitted DRG is not supported. Our physician reviewer found there was no documentation of pneumonia. Our reviewer also found that the enrollee was treated for an exacerbation of chronic obstructive pulmonary disease (COPD)/bronchitis. 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 hospital services billed with diagnosis related group (DRG) code 871.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-ray (D0270) provided on October 13, 2021.

You asked the Plan to pay for the bitewing x-ray. You say that you had a yearly checkup and a full mouth x-ray, then you had a large chip out of a tooth. You also say that you went in at a later date and they had to x-ray that single tooth to see if the base would hold a crown or needed to finish being removed. The Plan denied your request. The Plan says the frequency limit for this service has been exceeded.

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, bitewing x-rays (codes D0270, D0272, D0273, D0274, and D0277) are limited to one procedure per calendar year. The record shows that you received bitewing x-rays (D0274) on January 15, 2021 and your bitewing x-rays benefit has been exhausted.

Therefore, we decided that the Plan does not have to pay for the bitewing x-ray (D0270) provided on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve primary care provider (PCP) services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve PCP services to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available to you that can provide the services you are requesting.

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 primary care provider (PCP) services to be provided by 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 provided on June 8, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a trapeze bar attached to bed with grab bar (E0910), provided on October 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for a trapeze bar attached to bed with grab bar. You say that you need this item. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services received out-of-network.
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 a trapeze bar attached to bed with grab bar (E0910), provided on October 1, 2021 by an out-of-network (OON) provider.
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH 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 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 Feraheme (Q0138).
You asked the Plan to pre-approve Feraheme. The Plan denied your request. The Plan says that the medical coverage for Feraheme, which is a non-preferred Medicare Part B drug, did not meet criteria.
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 Feraheme. Our reviewer says that the elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our physician reviewer found the record indicates that the enrollee has anemia from chronic renal disease, not on dialysis. The requested medication is a new start. Our reviewer found that the provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. Our physician reviewer also found that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternative. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme (Q0138).