Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits you had with a urologist 
on April 29, 2021, and April 30, 2021. 
 
You asked the Plan to waive the copayments for the urology visits. You say that you had to return to the 
urologist's office on April 29, 2021, because you were bleeding.  You then had to return twice on April 30, 
2021, and you were charged a copayment each time. You don't believe you should have to pay the copayments 
for these additional visits. The Plan denied your request. The Plan says you were charged these copayments 
correctly. 
 
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 $35 
copayment per visit for specialist visits.  
 
You have been asked to pay a $35 copayment per visit for the urology visits. This copayment applies per visit, 
regardless of the reason for the visits. 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 the office visits you 
had with a urologist on April 29, 2021, and April 30, 2021.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for an emergency room visit (99285, 93010) provided on June 22, 2021. 
 
You asked the Plan to pay for an emergency room visit. You say that you assumed these tests would be 
covered. The Plan denied your request. The Plan says that an explanation of benefits from your primary insurer 
is required. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. There is no documentation 
provided that shows the Plan has sent the bill to the primary insurer or directed the provider to submit the bill to 
the primary insurer. Therefore, we decided that the Plan has to pay for an emergency room visit (99285, 93010) 
provided on June 22, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are medically necessary as the enrollee 
is a fall risk. The Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is 
ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis. The enrollee is medically stable and can receive further rehabilitation services at a 
lower level of care. Although further rehabilitation services would be appropriate to improve function, as a 
practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. The 
enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. The 
enrollee is medically stable without any acute exacerbations of chronic medical problems. The enrollee's 
physical function is at or near their baseline and they can receive services at a lower level of care. Admission to 
a SNF for inpatient skilled rehabilitation services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0266) and dry pressure 
mattress (E0184). 
 
You asked the Plan to pre-approve a semi-electric hospital bed and dry pressure mattress. You say that the 
requested items are a medical necessity for you. The Plan denied your request. The Plan says medical necessity 
rules for the requested items have not been met. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 a semi-electric hospital bed and dry 
pressure mattress. Our reviewer says that the requested items are not medically reasonable and necessary in this 
case. Our physician reviewer found that the criteria for a semi-electric bed have not been met. The 
documentation does not clearly reveal that enrollee's condition has failed positioning of the bed in ways not 
feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does 
not support a need for frequent or an immediate change in body position or special attachments that cannot be 
fixed on an ordinary bed. Additionally, the criteria for a dry pressure mattress have not been met. The enrollee 
is not completely immobile. The enrollee does not have limited mobility such that the enrollee cannot 
independently make changes in body position without assistance or make changes in body position significant 
enough to alleviate pressure. There is no evidence of a pressure ulcer on the trunk or pelvis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a semi-electric hospital bed and dry pressure mattress have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0266) and dry 
pressure mattress (E0184)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Corus Spinal System.  
You asked the Plan to pre-approve the requested services. You say that the enrollee's pain limits daily living 
activities. The Plan denied your request. The Plan says the system remains experimental for use in posterior 
cervical spine fusion.  
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 requested services. Our physician 
reviewer found that the Corus spinal system is experimental. More research is needed to show safety and 
efficacy. Therefore, the request is not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Corus Spinal System.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81302, 81330, 81345, 81404, 81405, 
81406, 81407, 81408, 81479) provided on December 8, 2020. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was a screening 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 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 (81302, 81330, 81345, 81404, 81405, 81406, 81407, 
81408, 81479) provided on December 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammogram (77067) provided June 3, 2021.

You asked the Plan to pay for the screening mammogram. You say that this is the first mammogram you have
had in 12 months. The Plan says that one mammogram every 12 months is covered for women aged 40 and
over and you are over 40, so this should be covered. The Plan denied your request. The Plan says this service
exceeds the maximum benefit frequency limitation.

The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed in
the Medicare rules section, are not covered. These rules say that enrollees are eligible for coverage of a
screening mammogram once every 12 months.

In this case, the records show that a screening mammogram coded as 77067 was provided on October 13, 2020.
The enrollee would not have been eligible until the 12-month time frame has passed. Based on review of the
file, a screening mammogram was provided less than 12 months prior to the visit at issue in this case.

Therefore, we decided that the Plan does not have to pay for the screening mammogram (77067) provided June
3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gender-affirming telescopic laryngoplasty surgery for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the medical appropriateness of this request cannot be evaluated without otolaryngology (ENT) notes.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was evaluated by an otolaryngologist on 8/27/21 for difficulty phonating. The enrollee was frustrated because he has not noted a decrease in the pitch of his voice. It is documented, "Unfortunately, we do not have any specific surgical procedures for masculinization of the voice. This occasionally occurs naturally with exogenous testosterone, but vocal fold changes in association with testosterone are highly variable." A voice evaluation on 8/27/21 strongly recommended voice treatment by a licensed speech-language pathologist. The documentation does not support that the requested gender-affirming telescopic laryngoplasty surgery is medically reasonable and necessary for the enrollee in this case.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve gender-affirming telescopic laryngoplasty surgery for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says that the criteria was not met.

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 health plan has not substantiated their denial in this case. The narrative
states that the "patient's medical records include the physician's office records, hospital records, nursing home
records, home health agency records, records from other healthcare professionals and test reports." None of
these records were provided to Maximus for review. It cannot be verified if the plan's denial reason is valid.
Therefore, we decided that the Plan has to pre-approve a continuous glucose monitor for the enrollee.

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: Favorable

We decided that the Plan has to pre-approve pembrolizumab (Keytruda).

You asked the Plan to pre-approve Keytruda. You say that the plan is to continue for up to two years post radiation. The Plan denied your request. The Plan says that treatment for more than 24 months is considered investigational for the enrollee's diagnosis.

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. Our physician reviewer found that the enrollee was diagnosed with metastatic transitional cell carcinoma and metastatic non-small cell lung cancer. The requested use of Keytruda is supported by the National Comprehensive Cancer Network (NCCN) compendia. The requested use is not listed as not indicated, not supported, or not recommended in any of the compendia. The documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 

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 have been met. Therefore, we decided that the Plan has to pre-approve pembrolizumab (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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the physical therapy visits. You say that the out-of-network provider is closest to your home. You say you do not want to drive far for therapy. The Plan denied your request. The Plan says the provider is 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 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. The record shows the in-network providers are located within the distance standards. Therefore, we decided that the Plan does not have to pre-approve the physical therapy visits to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) angiography of the neck provided on December 18, 2019.
You asked the Plan to waive the copayment for CT angiography. You say that the CT angiography was not done for your upper arm and the test needs to be re-done now. 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 $200 copayment for diagnostic radiology services in a provider's office. You have been asked to pay a $200 copayment for CT angiography. CT angiography falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 a computed tomography (CT) angiography of the neck provided on December 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Keytruda (J9271).
You asked the Plan to pre-approve Keytruda. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage for the requested treatment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. The file does not include medical records with specific information about the enrollee's condition. It cannot be determined whether a given drug is safe and effective for an enrollee without current medical records. Without this documentation, we cannot confirm that the Medicare coverage criteria for Keytruda have been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Keytruda (J9271).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Modafinil tablet for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this medication falls under Part D coverage.
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 Modafinil tablet for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve action adaptive cube pads (CPT code K0108) and ultra-low max recline retro fit kit (CPT code E1005), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the power recline is not medically necessary. The Plan states the approved wheelchair cushions include all parts needed for them to work correctly and the padding cannot be requested separately.

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 DME. Our physician reviewer found the documentation does not revel that the enrollee is at high risk for development of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. The October 1, 2021, neurology note indicates she has low tone. The criteria per Medicare's LCD: Wheelchair Options/Accessories (L33792) for the E1005 have not been met. The enrollee was approved for E2620 upgradeable back options and was approved in the past for the E2524. The request for the K0108 is not medically necessary. The criteria per Medicare's LCD: Wheelchair Options/Accessories (A52505) have not been met. The rules say that there is no separate payment for any part of a seat or back cushion, and that K0108 cannot be used for any cushion component as they codes are all-inclusive. Use of HCPCS code K0108 or any other HCPCS code to separately bill for added components such as the foam blocks, gel packs, air cells, or equivalent material is incorrect coding. 

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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve action adaptive cube pads (CPT code K0108) and ultra-low max recline retro fit kit (CPT code E1005), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998), 
provided from June 8, 2021, to June 9, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that you changed your blood pressure 
medication. You say that you had high blood pressure. You say that you called the paramedics. You say that 
you were advised to sign a release of liability and to have someone take you to the emergency room. You say 
that this happened twice. You also say that you do not understand why they did not want to transport you. The 
Plan denied your request. The Plan says the provider did not transport you. The Plan says that a refusal of 
transport form was signed. The Plan also says that if transport is not provided, the service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 8, 2021, to June 9, 2021. The ambulance 
benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the 
services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and 
treatment, no transport (A0998), provided from June 8, 2021, to June 9, 2021.