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

 We decided that the Plan does not have to waive the copayment for the visit you had with an urgent care specialist on July 2, 2021.  You asked the Plan to waive the copayment for the specialty visit. You say that you were sent to this provider by your primary care provider (PCP) because they were unavailable.  You said that you saw a Nurse Practitioner, not a doctor.  You stated that the Nurse Practitioner would not examine your neck even though you had been vaccinated.  You said that you should not have to pay this copayment simply because your PCP couldn't see you. The Plan denied your request. The Plan says you were charged this copayment 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 $45 copayment for physician/practitioner specialty visits.   You have been asked to pay a $45 copayment for the specialty visit. This copayment applies regardless of the reason for the visit, and it applies for both physician and practitioner services. 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 the visit you had with an urgent care specialist on July 2, 2021.   Your complaint about your primary care physician's availability 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: 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 services are medically necessary. The Plan denied your request. The Plan says your care needs can be met at a lower level of care.
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, based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for aortic valve replacement. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on September 28, 2020.
You asked the Plan to pay for the provided services. You say that the provider documented a detailed patient history. The Plan denied your request. The Plan says the enrollee did not receive video or telephonic visit by the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that knee orthoses are only covered under certain medical indications. We looked at the file and Medicare rules. The records in the case file only include subjective descriptions of the enrollee's condition. There are no previous records from the ordering physician documenting her condition or previous treatment. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on November 16, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you would like reconsideration because the member requested a routine eye exam with a $0 copayment. The Plan denied your request. The Plan says the claim for the specialty copay of $45 correctly processed in accordance with the member's contract.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $45 copayment for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye. The enrollee has been asked to pay a $45 copayment for the office visit. This specialist visit falls within the Vision Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit (99214) provided on November 16, 2020.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee's needs could be met at a lower level of care.
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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve the requested ventilator. The Plan denied your request. The Plan says the enrollee is not compliant with the usage of the device.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our physician reviewer found that this enrollee has chronic obstructive pulmonary disease with a hospitalization in August of 2020, for hypoxic and hypercarbic respiratory failure. The enrollee responded to treatment with BiPAP while hospitalized. A home ventilator is considered not medically necessary because the enrollee's needs could be met with BiPAP. The ventilator is being used as BiPAP, which is not covered by Medicare. There is no documented failure of BiPAP. Therefore, the requested ventilator 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 the requested ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that the enrollee has been progressing well with daily skilled care and would benefit from ongoing coverage. The Plan denied your request. The Plan says the enrollee's needs are now mainly custodial in nature.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care.
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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional home health occupational therapy visits.
You asked the Plan to pre-approve the additional home health occupational therapy visits. You say that the enrollee needs six months of physical therapy, occupational therapy, and speech therapy from her home. You also say that this request is reasonable, and should not be denied because the enrollee's rehab potential is great. The Plan denied your request. The Plan says the request for 12 additional home health occupational therapy visits does not meet medical necessity criteria for approval.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional home health occupational therapy visits. Our reviewer says that the services are not medically reasonable and necessary for the enrollee. Our physician reviewer found the documentation does not support that the enrollee requires further skilled rehab services to provide treatment that is medically necessary. Our reviewer found that the enrollee does not require rehab services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Our physician reviewer also found that the enrollee's functional improvement plateaued, and she should be independent with a home exercise 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 the additional home health occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional home health occupational therapy visits.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the alanine amino transferase (ALT) testing provided on July 7, 2021, billed with code 84460.  You asked the Plan to pay for the ALT testing. You say that this should be paid. The Plan denied your request. The Plan says that payment was made for this test on the same date of service to another provider. There is no evidence that more than one test was performed.  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 has failed to submit evidence that payment was made for this code on the same date of service to another other provider. Without this evidence, it cannot be determined that the denial of payment is correct. Therefore, we decided that the Plan has to pay for the alanine amino transferase (ALT) testing provided on July 7, 2021, billed with code 84460.   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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the $40 copayment for an occupational therapy evaluation provided on March 15, 2021.
You asked the Plan to waive the cost share for an occupational therapy visit and an orthosis. You say that you do not believe this bill is correct. The Plan denied your request. The Plan says this cost share was charged based on the Plan contract agreement. We overturned the Plans denial stating the Plan should hold you harmless for the cost of the orthosis because the denial was for an issue with the place of service billed on the claim which you have no control over. The Plan requested are reopen and stated that you were not being charged for the orthosis, only the $40 copayment for the occupational therapy visit.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says that you must pay $40 copayment for each occupational therapy visit.
The Plan has provided documentation to show your only cost share is for the occupational therapy evaluation and not for the orthosis. You have been asked to 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 charged for an occupational therapy evaluation provided on March 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Nulojix (Belatacept) for the enrollee.
You asked the Plan to provide coverage for Nulojix (Belatacept). You say that Nulojix (Belatacept) is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated we did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Nulojix (Belatacept).Our Physician Reviewer determined that while the requested use of Nulojix is not FDA-approved for the enrollee's diagnosis, it is supported by clinical research. The Plan argues that there is no evidence within the Medicare-approved compendia, authoritative medical literature, and/or accepted standards of medical practice that supports the use of Nulojix without Basiliximab induction, and Mycophenolate mofetil. The Plan is correct in this case. Nulojix is FDA-approved for the prophylaxis of renal transplant rejection, in combination with Basiliximab, Mycophenolate, and Corticosteroids. The documentation in the case file does not support that Nulojix (belatacept) will be used in combination with Basiliximab and Mycophenolate mofetil. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nulojix (Belatacept) have not been met. Therefore, we decided that the Plan does not have to provide coverage for Nulojix (Belatacept) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90834) provided on June 1, 2021, by a provider not enrolled in the Medicare program.  You asked the Plan to pay for psychotherapy services. You say that the requested services were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue is not enrolled in the Medicare program.  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 psychotherapy services (90834) provided on June 1, 2021, by a provider not enrolled in the Medicare program.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve spinal surgery.  You asked the Plan to pre-approve spinal surgery. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous distraction devices remain experimental. More research is needed to show safety and efficacy of the devices.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found 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 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.