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

 We decided that the Plan does not have to pay for radiologic examination, chest (71046) set-up portable x-ray equipment (Q0092) and transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location (R0070) provided July 28, 2021.  You asked the Plan to pay for the portable x-ray services. You say that you are the only portable provider who could provide portable diagnostic services for the enrollee. You are requesting reconsideration of the claim and approval of a one time waiver to pay benefits at the network level. The Plan denied your request. The Plan says this claim was processed correctly per the Evidence of Coverage.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $750 deductible which applies to Outpatient diagnostic tests and therapeutic services and supplies.   The item or service you asked the Plan to pay for falls within the benefit category Outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible which applies to Outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time the portable x-ray services was received on July 28, 2021. Therefore, we decided that the Plan does not have to pay for radiologic examination, chest (71046) set-up portable x-ray equipment (Q0092) and transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location (R0070) provided July 28, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospice care billed on June 1, 2021.  You asked the Plan to pay for hospice care. You say that the claims are for hospice room and board services only. You say that the claim should be reconsidered for payment so the skilled facility can be paid. The Plan denied your request. The Plan says the claim was billed incorrectly.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for hospice care billed on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the urology visit you had on May 4, 2021.  You asked the Plan to waive the copayment for the urology visit. You say that you shouldn't have to pay this copayment because you went to the appointment expecting a bladder exam, but it did not happen.  The urologist told you that you had to make a separate appointment for that.  You said that since you had nothing done, you shouldn't have to pay this copayment. 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 $40 copayment for visits with a specialist.   You have been asked to pay a $40 copayment for the urology visit.  This copayment applies regardless of the extent of services received during the visit. 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 urology visit you had on May 4, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from April 2, 2021, to May 14, 2021.  You asked the Plan to pay for the SNF care. You say that you should not have to pay anything over your maximum out of pocket cost of $7,550. You say that you needed more time at the facility. You also say that you stayed based off the judgement of the providers. The Plan denied your request. The Plan says that the enrollee did not require skilled nursing services. The Plan also says that the occupation therapy services that were provided could have been received on an outpatient basis.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF care. Our reviewer says that the SNF care is not medically necessary. Our physician reviewer found the provided documentation did not show that you required daily skilled nursing services. The reviewer found that you required daily skilled therapy services. The provided documentation indicates that you made substantial improvement in ambulation and transfers during the period in question. The reviewer found that you required the services on an inpatient basis in a skilled nursing facility setting. Therefore, the reviewer found that the SNF care was medically reasonable and 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from April 2, 2021, to May 14, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new a respiratory assist device (E0470), and a humidifier (E0562) due to recall.
You asked the Plan to pre-approve a new a respiratory assist device (E0470), and a humidifier (E0562). You say that this equipment is medically necessary for your use. The Plan denied your request. The Plan says this device is less than five years old and all issues pertaining to replacement due to possible damage need to be handled through the durable medical equipment provider. The Plan states that although there was a recall on the machine, you are still able to use the current device. We overturned the Plans denial. The Plan requested a reopen and stated that the equipment you have is still working and that the Plan is working with the provider to accommodate the recall, and the repair but the Plan is not required to approve brand new equipment if your less than five-year-old equipment can be repaired to accommodate the recall.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that equipment less than five years old that can be repaired will not be replaced. Medicare rules say that if necessary, the Plan must purchase or rent a replacement item for the beneficiary to use. In this case, your current equipment was working, and the Plan could have rented temporary equipment. It was your responsibility to work with the equipment provider to facilitate the recall as opposed to asking for brand new equipment. Therefore, we decided that the Plan does not have to pre-approve a new a respiratory assist device (E0470), and a humidifier (E0562) due to recall.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ultomiris for the enrollee.
You asked the Plan to pre-approve Ultomiris. You say that Ultomiris is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. We overturned the Plans denial. The Plan requested a reopen and stated that we did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Ultomiris (Ravulizumab-cwvz). Our Physician Reviewer determined that the requested services were medically reasonable and necessary. The Plan argues that Ultomiris is not approved by the Compendia for this treatment, and that the clinical value and effectiveness of Ultomiris in the setting of APLS have not been demonstrated in the peer-reviewed literature. While the plan agrees that is unreasonable to discontinue off -label use of Soliris due to the documented effective treatment since 2016, the extrapolation to the use of another off-label drug seems incorrect. Our Medical Director has concluded that the Plan is correct in this case. The enrollee is a 49-year-old man with antiphospholipid syndrome complicated by renal failure. The enrollee has been successfully treated with Soliris (Eculizumab) since April, 2016. The documentation does not support that Ultomiris (Ravulizumab-cwvz) is medically reasonable and necessary in this case, as defined by Medicare. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ultomiris have not been met. Therefore, we decided that the Plan does not have to pre-approve Ultomiris for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a genicular nerve block.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is insufficient evidence to support its efficacy for the treatment of osteoarthritis knee pain.  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 you have a history of chronic bilateral knee pain due to osteoarthritis. You have had treatment with medications, physical therapy and are status post arthroscopy. Genicular nerve blocks and genicular nerve radiofrequency ablations are considered investigational and not medically necessary for the treatment of chronic knee pain.     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 genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on June 22, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on June 22, 2021.   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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce this copayment.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the type of provider seen and the Plan contract agreement. We administratively overturned the Plans denial because a 2020 Evidence of Coverage had not been submitted with the case file. The Plan requested a reopen and provided a copy of the correct 2020 Evidence of Coverage.
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 $35 copayment for specialist services provided. The provider you were seen by is considered to be a specialist. 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 or reduce the $35 copayment charged for specialist services provided on July 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies provided to the enrollee on March 19, 2021.
You asked the Plan to pay for these supplies. You say that this claim should be paid. The Plan denied your request. The Plan says the units billed are over the allowed amount. We overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says this claim which billed for 1 month supply to equal 1 unit of service, denied because this exceeds the maximum number of units for this period. The records show the provider billed this service previously during the months of January and February. These claims billed a total of 3 units, which is equivalent to a 90-day supply. The records show a claim for 1 unit billed on January 18, 2021, January 25, 2021, and February 17, 2021.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find the units billed exceeds the units allowed. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for diabetic supplies provided to the enrollee on March 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services for the enrollee.
You asked the Plan to pre-approve home health services. You say that home health services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. We overturned the Plans denial due to a lack of notice in the case file of non-covered continuing coverage.
The Plan requested a reopen and stated that this was not a request for continued service but a request for new services and therefore a notice of non-coverage for continued services would not apply.
The Plan is correct in this case. A notice of non-coverage would not apply in this case. 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. Based on the medical records provided, the enrollee does not meet the requirements listed in the Medicare rules section for approval of home health services. Therefore, we decided that the Plan does not have to pre-approve home health services for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for integrated biopsychosocial assessment (90791) provided June 30, 2021.  You asked the Plan to pay for the behavioral health services. You say that the provider is a professional counselor with special training and skill in assessing patient mental health and treating cognitive psychological and behavioral disorders. Therefore, this claim should be paid. The Plan denied your request. The Plan says this provider type is not eligible 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 integrated biopsychosocial assessment (90791) provided June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for intraoperative lymph node identification (38900) provided on March 16, 2021.  You asked the Plan to pay for intraoperative lymph node identification. You say that this is supported by the records. The Plan denied your request. The Plan says this was billed without an appropriate primary procedure.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code intraoperative lymph node identification is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for intraoperative lymph node identification (38900) provided on March 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Aduhelm (Aducanumab) for the enrollee.
You asked the Plan to provide coverage for Aduhelm (Aducanumab). You say that Aduhelm (Aducanumab)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 that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Aduhelm (Aducanumab). Our Physician Reviewer determined that Aduhelm is medically reasonable and necessary for the enrollee in this case. The reviewer found that the enrollee's condition meets criteria for coverage of Aduhelm. The Plan argues that there is no documentation of a Clinical Dementia Rating Global Score or a Mini-Mental State Exam, to establish that the enrollee has a mild case of Alzheimer's disease. The plan states that the enrollee has had a "precipitous decline in the last 6 months," indicating that her dementia is rapidly progressing, and notes that the enrollee has been treated with Namenda (which is indicated for moderate to severe dementia) for over a year.
The Plan is correct in this case. Aduhelm is FDA-approved for the treatment of Alzheimer's disease in patients with mild cognitive impairment or mild dementia stage of disease, the population in which treatment was initiated in clinical trials. The clinical information in the case file does not support that the enrollee has a mild dementia stage of disease. MRI imaging in this case demonstrates the presence of cerebrovascular disease, which is evidence of a mixed etiology for the enrollee's symptoms. In addition, it has not been shown that Aduhelm is at least as beneficial as existing and appropriate and available medically appropriate alternatives for this enrollee. The available documentation in the medical records is insufficient to demonstrate that Aduhelm is safe and effective and otherwise 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 Aduhelm (Aducanumab) have not been met. Therefore, we decided that the Plan does not have to provide coverage for Aduhelm (Aducanumab) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments charged for outpatient services provided from February 2, 2021, to February 23, 2021.
You asked the Plan to waive these copayments. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says while the claims were originally processed in error, they have since been corrected, leaving you a cost share of $3.86 and $6.36. We partially overturned the Plans denial. The Plan requested a reopen and stated that we did not interpret the Plan contract correctly.
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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20 copayment for outpatient lab and diagnostic services.
In this case, you are being asked to pay less than the actual copayment expectation for each service which is a cost share of $3.86 and $6.36. 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 charged for lab services provided from February 2, 2021, to February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network genetic testing provided on January 30, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. We overturned the Plans denial stating it was not clear who ordered these services. The Plan requested a reopen and confirmed neither the ordering physician nor the provider were contract providers.
The Plan is correct in this case. 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 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 out of network genetic testing provided on January 30, 2020.