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

We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device (22869, 22870).
You asked the Plan to pre-approve the Vertiflex device. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says this service is considered experimental and investigational as there is a lack of evidence to support interspinous spacer devices are as safe and effective as the gold standard of decompression.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day reader continuous glucose monitor (CGM).

You asked the Plan to pre-approve a Freestyle Libre 14 day reader. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 14 day reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day reader continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmental pneumatic compression device with calibrated gradient pressure (E0652, E0667).

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is only lymphedema extending up to the level of the lower extremities.

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 device. Our reviewer says that the requested iservices are not considered medically reasonable and necessary in this case. Our physician reviewer found you do not have lymphedema of the chest, trunk, or abdomen on an objective physical exam in the submitted documentation. You do not have unique characteristics that would indicate the segmented pump over a standard pump. The documentation does not reveal evidence of a trial and failure of a standard pump with detailed measurements.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a segmental pneumatic compression device with calibrated gradient pressure (E0652, E0667).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services billed for date of service July 3, 2020 under Claim A.

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 Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the proper billing criteria. The Plan provided additional claim information and states that two claims were submitted by two different hospitalist billing groups and are for the same provider, for the same date of service with the same service code (CPT 99285). The first claim submitted has been paid for these services under a separate claim. The plan cannot pay this provider again for the same services under a different hospitalist billing group.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for emergency room services billed under claim number Claim A for date of service July 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on October 30, 2020.
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 testing is not covered.
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on October 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 17, 2020.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your record does not show that you require daily skilled nursing or skilled therapy in a SNF setting.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve parathyroid planar imaging (78071).

You asked the Plan to pre-approve parathyroid planar imaging. You say that this imaging service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that this service is not medically necessary for the enrollee because they are not on weight management program.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pre-approve parathyroid planar imaging. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the patient is an 83-year-old female with hyperparathyroidism status post right thyroidectomy as part of thyroid nodule workup and recently more elevated parathyroid hormone (PTH) after a recent fall. Parathyroid nuclear scan was requested. The patient refused this test in the past but was willing to complete it now. It is requested to help identify suspicious lesions which is reasonable and medically necessary considering prior history of thyroid nodules and elevated PTH.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of parathyroid planar imaging have been met. Therefore, we decided that the Plan has to pre-approve parathyroid planar imaging (78071).

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: Unfavorable

We decided that the Plan does not have to pre-approve anticancer treatment with Alimta (J9305), Keytruda (J9271), and Dexamethasone Sodium Phosphate (J1100).

You asked the Plan to pre-approve Alimta, Keytruda, and Dexamethasone Sodium Phosphate. You say that the requested therapy could be helpful for the enrollee. The Plan denied your request. The Plan says the requested combination therapy is not supported for the enrollee's condition.

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 Alimta, Keytruda, and Dexamethasone Sodium Phosphate. Our reviewer says that the requested treatment regimen is not medically necessary. Our physician reviewer found that the use of the requested drugs is not FDA-approved for the enrollee's diagnosis. The enrollee had progression of disease on Alimta and a different immunotherapy. The use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Alimta, Keytruda, and Dexamethasone Sodium Phosphate have not been met. Therefore, we decided that the Plan does not have to pre-approve anticancer treatment with Alimta (J9305), Keytruda (J9271), and Dexamethasone Sodium Phosphate (J1100).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) provided October 17, 2019.
You asked the Plan to pay for the office visit. You say that claim was initially billed to Medicare where we got the denial as covered by another payer which caused delay. Please review process this reconsideration request towards the payment. The Plan denied your request. The Plan says this claim was received past the timely filing limitation.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the office visit was not filed until 12/01/2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99214) provided October 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient hospital care for a ketamine infusion.

You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says because the requested procedure is not medically necessary, the related inpatient hospital admission is also not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the request is for inpatient admission for ketamine infusion to treat pain and depression. In this case, there are no records. The documentation provided does not indicate that the ordering physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The record does not indicate that the planned infusion is approved. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for acute inpatient hospital care for a ketamine infusion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoride treatment (D1208) and the unspecified preventive service (D1999 x 2) provided from October 22, 2020, and November 3, 2020.

You asked the Plan to pay for the dental services. You say that you were not notified or aware that the fluoride service would not be covered. You also say that you received conflicting information from the provider and the Dental Plan on whether the service was covered. The Plan denied your request. The Plan says application of fluoride is not listed as a covered service. The Plan says that unspecified preventive service is not listed as a covered service either.

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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fluoride treatment (D1208) and the unspecified preventive service (D1999 x 2) provided from October 22, 2020, and November 3, 2020.
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 SNF care. You say that SNF care is medically necessary and reasonable. The Plan denied your request. The Plan says the rules for SNF care have 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 a 93-year-old female with a past medical history of hypertension, anemia, muscle weakness and repeated falls who was admitted to a skilled nursing facility and discharged. There is no documentation that the patient requires skilled nursing services and no documentation that this patient requires skilled therapy services. Based on the medical records provided, this patient does not require the services on an inpatient basis that can only be provided in a SNF. The enrollee's needs appear to be custodial in this case and do not require SNF 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 SNF care 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and only requires additional short-term acute care services for additional weaning and care which can safely be received at the current acute care facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed the enrollee is nearing baseline. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2394) and the limited oral evaluation (D0140) provided on January 15, 2021.

You asked the Plan to pay for the dental services. You say that you are interested in the $58 charge for the limited oral evaluation. You say that you only had 1 x-ray done and then the dentist came in and said she would fix your tooth. You also say that you have gone to the dental practice since you were a teenager. The Plan denied your request. The Plan says Filling is not listed as a covered service. The Plan also says limited oral evaluation is not listed as a covered service either.

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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the filling (D2394) and the limited oral evaluation (D0140) provided on January 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the services the enrollee requires are available at the short-term care hospital. The elements of the coverage rule are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided.
You asked the Plan to pay for the dental services. You say that you were informed that you would have the same coverage for in network and out of network dental benefits upon enrollment. You say that the Plan should pay the full cost share. The Plan denied your request. The Plan says there is a 50% coinsurance for preventive dental visits. The Plan also says that the claim processed correctly.
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, there is a 50% coinsurance for preventive dental visits.

CPT Code     Billed     Allowed     Coinsurance     Plan Paid     Your Responsibility
D0120            $44         $44             50%               $22                    $22
D1110           $104        $104            50%            $52.50                $52.50
TOTAL:                                                                $74                    $74

Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 2, 2020.
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.
The Plan must follow Medicare rules. Medicare rules say that modifier 26 is required for separate PC payment. We looked at the file and Medicare rules. The file shows that the procedure codes at issue were not billed with the required -26 modifier for separate payment. 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 pay for the laboratory services rendered on October 2, 2020.