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

We decided that the Plan does not have to provide coverage for a transfer from an inpatient rehabilitation
facility (IRF) to a skilled nursing facility (SNF).
You asked the Plan to provide coverage for this transfer. You say that this transfer is medically necessary. The
Plan denied your request. The Plan says medical necessity has not been established for this transfer. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria. The Plan says in this case, the enrollee was already receiving daily skilled therapy in an inpatient
rehabilitation facility. The IRF provider documented that a continued comprehensive course of acute inpatient
rehabilitation was reasonable and necessary. The Plan notes the enrollee was already receiving the skilled
therapy services required in the IRF and transfer to a SNF is unnecessary.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the services
requested for coverage must be medically necessary. 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
provide coverage for this transfer. Our physician reviewer found based on the documentation provided, the
enrollee would likely be better served at the IRF and that the enrollee would likely plateau quickly in a SNF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this transfer were not met at the time of the appeal.
Therefore, we decided that the Plan does not have to provide coverage for a transfer from an inpatient
rehabilitation facility (IRF) to a skilled nursing facility (SNF) for the enrollee
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 enrollee needs IRF and the enrollee's needs cannot be safely met by home health or skilled nursing. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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. While the enrollee may need physical and/or occupational therapy, there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Eliquis tablet.
You asked the Plan to pre-approve the Eliquis tablet. You say that the drug is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.
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 the Eliquis tablet
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital and emergency room
services provided from August 23, 2021, to August 29, 2021.
You asked the Plan to waive the copayment for the inpatient hospital and emergency room services. You say
that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied
correctly based on the services provided.
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 Emergency care and a $200 copayment per day of Inpatient hospital care.
You have been asked to pay a $90 copayment for an emergency room visit and a $1,200 copayment for six
days of inpatient hospital and emergency room 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 inpatient hospital and emergency room services provided from August 23, 2021, to August 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on July 26, 2021.
You asked the Plan to pay for the dental services. You say that you were unaware what procedures were done. You also say that you feel they were unnecessary for a second opinion. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that 1 complete series x-ray is covered every 3 plan years. The Plan also says that the frequency limits have 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 and the services are listed as covered, the frequency limit has been exceeded.
The record shows that the Plan paid for a comprehensive oral evaluation and complete series x-ray that you received on November 20, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on July 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive
pulmonary disease (COPD) with chronic hypoxemic respiratory failure. He has not tried and failed the Plan's
required drug, Perforomist. The records do not show that the required drug would be contraindicated or less
effective; therefore, Brovana is not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Brovana.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing provided on August 11, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered
service.
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M are non-covered
for Cxbladder testing.
We looked at the file and Medicare rules. The Cxbladder testing in this case was billed with code 0012M. This
is not a covered code for this testing. Based on this information, we decided that Medicare rules for coverage of
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the Cxbladder
testing provided on August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a prosthetic provided on August 26, 2021.
You asked the Plan to waive the copayment for the prosthetic. You say that the services should be covered. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided.
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 10% coinsurance for Durable medical equipment (DME) and related supplies.
You have been asked to pay a 10% coinsurance for the prosthetic (allowed is $4,452 x 10% = $445.20). Prosthetics fall within the Durable medical equipment (DME) and related 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 prosthetic provided on August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the aflibercept injection (J0178) provided on September 22, 2021.
You asked the Plan to waive the coinsurance for the drug injection. You say that the plan should pay the full cost of this service because you are frustrated that you had to change your vision provider. The Plan denied your request. The Plan says this service is covered by your insurance, and you have been asked to pay 20% coinsurance for this service. This claim was processed correctly and in accordance with your 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). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B Prescription Drugs.
You have been asked to pay $366.56 for the drug injection. The provider billed the Plan $4,200 for this service, but the Plan's maximum allowed cost for the drug injection is $1,832.82. You are responsible for 20% coinsurance on the Plan's allowed amount for Medicare Part B Prescription Drugs, and the Plan covers the remaining cost. ($1,832.82 x 20% = $366.56). 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 coinsurance for the aflibercept injection (J0178) provided on September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and core buildup, including any pins when required (D2950) provided October 11, 2021.
You asked the Plan to pay for the comprehensive oral exam and core buildup. You say that you needed these services and cannot afford the cost. The Plan denied your request. The Plan says you have exceeded the frequency limit for the comprehensive oral exam and the core buildup is not a covered service.
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 covers the comprehensive oral exam once per calendar year. We looked at the file and Medicare rules. A comprehensive oral exam was previously covered on October 6, 2021.
Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral
exam has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the core
buildup is not among those covered services. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation - new or established patient (D0150) and core buildup, including any pins when
required (D2950) provided October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for drug therapy services provided to the enrollee on June 9, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain not supported.
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, the CPT Code Manual definition of the denied codes is: CPT 80157: Carbamazepine; free CPT 80159: Clozapine
CPT 80162: Digoxin; total CPT 80173: Haloperidol CPT 80177: Levetiracetam CPT 80201: Topiramate We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found based on the medical records provided there is no documentation that the billed services can be verified in this case. The records indicate that the specimen for testing was a urine collection and not a blood specimen collection as would be required to support the billed codes. We looked at this coder'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 pay for drug therapy services provided to the enrollee on June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2020, V2203, V2744, V2750, V2784) purchased on October 14, 2021.
You asked the Plan to pay for the eyeglasses. You say that you have had this plan for years and never had an issue getting these glasses. This is an in-network provider, and these are covered services. The Plan denied your request. The Plan says your benefit covers routine eyewear once every 2 years. You previously purchased covered eyeglasses on February 12, 2020, which is less than two years before the date in question. The glasses purchased on October 14, 2021, exceed the frequency limitations of your benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services once every 2 years. We looked at the file and the Plan's rules. Documentation shows that you previously purchased covered eyeglasses in February 2020, which is less than 2 years before the date in question of October 14, 2021. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2203, V2744, V2750, V2784) purchased on October 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Xiidra drops.
You asked the Plan to pre-approve Xiidra. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Xiidra drops.
Benefits for Xiidra 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.
You asked the Plan to pre-approve Ondansetron. The Plan denied your request. The Plan says this is not a
covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered 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 Ondansetron.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.
You asked the Plan to pre-approve Eliquis. The Plan denied your request. The Plan says Eliquis is not medically reasonable and necessary.
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 Eliquis
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for continued skilled nursing facility services after
August 22, 2021.
You asked the Plan to pre-approve continued skilled nursing facility services. At the time of the appeal, you
stated continued skilled nursing facility services were medically necessary because you lived alone and needed
continued care to get stronger. The Plan denied your request. The Plan says Medicare coverage criteria for
continued care were not met. Maximus administratively overturned the Plans denial because the case file
lacked the required notice of non-coverage documentation. The Plan requested a reopen and provided the
required documentation.
The Plan is correct in this case. 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.
Based on the medical records provided, as of August 22, 2021, you no longer required skilled nursing and/or
skilled therapy services on a daily basis at an inpatient SNF left of care. Medicare coverage criteria for this
level of care were no longer met. Therefore, we decided that the Plan does not have to provide coverage for
continued skilled nursing facility services after August 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics provided by Winkley and Orthotics Prosthetics.
You asked the Plan to pre-approve foot orthotics. You say that you have trouble walking due to foot and ankle problems. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics provided by Winkley and Orthotics Prosthetics.