Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on August 15, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says there are no claims on file with the ordering physician listed in the member's claims history.
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 pay for the lumbar-sacral orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not indicate that there is recent injury, surgical procedure, or objective evidence of weakness, deformed spine, or mobility restricted by 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on August 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider
on October 26, 2020.
You asked the Plan to pay for laboratory services. You say that the treating physician determined the test is
medically necessary to determine the most appropriate course of treatment. You say that test is not available
through any other laboratory and reimbursement should be allowed. The Plan denied your request. The Plan
says prior authorization was required but not obtained.
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 requested 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 laboratory services provided by an out-of-network
provider on October 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Truxima.

You asked the Plan to pre-approve Truxima. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Truxima. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a history of autoimmune hemolytic anemia. Truxima is not approved for the treatment of warm autoimmune hemolytic anemia at a dosing frequency of more than 4-6 months (provider is requesting a 7th cycle at only 7 weeks post the last cycle), nor is Truxima approved for use in combination with Gammunex therapy, for the indication, and thus the dosing and combination use is off label. The documentation supports that the requested use of Truxima is not FDA-approved for the enrollee's diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-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 Truxima have not been met. Therefore, we decided that the Plan does not have to pre-approve Truxima.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that the enrollee needs aggressive therapy.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 metabolic encephalopathy, urinary tract infection and pneumonia and as discharged home on April 13, 2021. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment bymultiple 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided by an out-of-network provider from July 6, 2020, through September 9, 2020.

You asked the Plan to pay for nursing facility care. You say that the treatment received was medically necessary and the claim should be processed for payment. The Plan denied your request. The Plan says prior authorization was required but not obtained.

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 requested 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 nursing facility care provided by an out-of-network provider from July 6, 2020, through September 9, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay foran emergency department visit (99285) on August 19, 2020.You asked the Plan to pay foran emergency department visit. You say that the provided services were billed correctly.The Plan denied your request. The Plan says code 99284 is more appropriateand has approved payment for 99284.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 code 99285 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function."We asked our physicianreviewer 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 an emergency department visit. Our reviewer says that the billed service is not supported by documentation. Our physician reviewer found that the documentation submitted does not meet the above criteria. The emergency room documentation supports a comprehensive history and exam; however, medical decision making supports a moderate level, due to laboratory, radiology and intravenous therapy, which would lower the level of evaluation and management to CPT 99284.To report evaluation and management code, all criteria must be met for history, exam,and medical decision making.In this case, CPT 99285 is not supported.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an emergency department visit, coded 99285,have not been met.Therefore, we decided that the Plan does not have to pay foran emergency department visit (99285) on August 19, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on October 15, 2020.
You asked the Plan to pay for the bitewing x-rays. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service is not covered.
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. The only covered x-rays listed under the Plan are complete series of intraoral x-rays (D0210) and panoramic x-ray (D0330). Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on October 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe ambulance transport provided on September 20, 2020.You asked the Plan to waive the coinsurance forthe ambulance transport. You say that if you were transferred to another hospital it would have taken a serious amount of time. You say you are appealing this bill.The Plan denied your request. The Plan says the coinsurance applied 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 mustpay 20% coinsurance for each one-way Medicare-covered trip.You have been asked to pay $239.25, which is 20% of the allowed amount for the ambulance transport. The allowed amount is $1,196.22 (20% x $1,196.22 = $239.25). The ambulance transport falls within the "Ambulance Services" 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 coinsurance forthe ambulance transport provided on September 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the miscellaneous durable medical equipment (DME) supply and knee orthosis provided on August 29, 2020.
You asked the Plan to pay for the miscellaneous DME supply (A9900) and knee orthosis (L1852). You say that the knee orthosis and miscellaneous supplies were medically necessary. The Plan denied your request. The Plan says there is no itemized shipping/billing invoice to indicate the specific supplies.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. The Proof of Delivery does not have a description of the items delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the miscellaneous DME supply and knee orthosis provided on August 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea home ventilator for the enrollee.You asked the Plan to pre-approvethe ventilator. You say that this is medically necessary.The Plan denied your request. The Plan says medical necessity was not established.The Plan must follow Medicare rules. Therules 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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer foundthat in this case, the enrollee has hypercapneic respiratory failure upon admission. An oxygenation evaluation on January 20 2021 demonstrated a resting saturation of 97%, an ambulation oxygenation of 88% and ambulatory oxygenation of 94% on 4 l nasal cannula. The documentation indicates that she is on BiPap in the hospital. The need for the use of a home ventilator is not objectively supported in the medical record.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 ventilator have not been met.Therefore, we decided that the Plan does not have to pre-approvea home ventilator for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. 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 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for abdominal pain and chest pain ad was treated for pancreatitis, bacteremia, urinary tract infection and coronary artery disease. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you 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-approveacute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis (L0650) provided on July 28, 2020.
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that if a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not 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 pay for this item. Our reviewer says that the lumbar sacral orthosis provided is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has low back pain from degenerative disc disease. In this case, the documentation does not provide evidence of a credible objective examination of the enrollee to establish the medical necessity or reasonableness of the provided item as defined by Medicare rules. The elements of the coverage rules are not satisfied.
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 item have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis (L0650) provided on July 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment charged for a diagnostic colonoscopy provided
on August 13, 2020.
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 claims submitted by the
provider and the Plan contract agreement. Maximus overturned the Plans denial stating medical records were
not submitted for review. The Plan requested a reopen and provided additional information.
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 $450 copayment for outpatient hospital or outpatient surgery services. The Plan
has provided documentation to show this was a diagnostic colonoscopy provided in an outpatient hospital
setting. 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 charged for a diagnostic colonoscopy provided on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary bone graft (CPT 21210) and an associated
inpatient stay for the enrollee.

You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan
denied your request. The Plan says this is not a covered benefit.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a maxillary bone graft
(CPT 21210) and an associated inpatient stay for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe porcelain crown (D2740) provided on September 21, 2020.You asked the Plan to waive the cost share forthe dental service. You say that you are sure that you paid more than the allowed amount for this service.The Plan denied your request. The Plan says the crown you received was processed and paid on an alternate benefit. The Plan says that if a method of treatment is more costly than is customarily provided, benefits will be paid on the least costly method of treatment, and you will be responsible for the remaining balance. 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 crowns are a covered service, the claim was processed and paid with an alternate benefit. You are responsible for the remaining balance. The record shows that the allowed amount for D2740 is $904, and the allowed amount for D2751 is $792. The difference in the allowed amounts is $112. TheEvidence of Coverage states that thePlan covers50% of the allowed amount for crowns($7922= $396). $112 + $396 = $508. Therefore, we decided that the Plan does not have to waive the cost share forthe porcelain crown (D2740) provided on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that the requested hyperbaric oxygen therapy is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for hyperbaric oxygen therapy.
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 hyperbaric oxygen therapy. Our reviewer says that the enrollee does not meet criteria for hyperbaric oxygen therapy. Our physician reviewer found the enrollee is with a diabetic foot wound. A request for HBO therapy was made. The provided notes show that the wound is healing with standard treatment and there were no signs of infection. There was insufficient detail documented regarding dietary efforts, glucose control efforts, or debridements to help treat the wound effectively. Therefore, this request for HBO criteria is not met as the enrollee does not have a listed indication for HBO therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.