Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided October 21, 2019 to October 29, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that please see medical records, waiver of liability and authorization. Please process.The Plan denied your request. The Plan says the admission was approved for observation level of care. Inpatient level of care was 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 indenying 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  while the records support an initial observation level of care to further evaluate the enrollee's chest pain, the lack of daily records does not support a conversion to inpatient status or a need for eight midnights of inpatient level care.  While the discharge summary indicates that the enrollee expressed suicidal ideation, it is unknown on which day this occurred, and ultimately this complaint did not prevent the enrollee from being discharged to home.  As such, the documentation is insufficient to support the need for, or timing of, inpatient level 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 acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided October 21, 2019 to October 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abutment supported porcelain/ceramic crown (D6058).

You asked the Plan to pre-approve the abutment supported porcelain/ceramic crown. You say that this service is covered under your dental coverage with the Plan.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.Therefore, we decided that the Plan does not have to pre-approve an abutment supported porcelain/ceramic crown (D6058)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe back brace (L0650) provided on September 12, 2020.You asked the Plan to pay forthe back brace. You say that you would like reconsideration because this equipment is medically necessary.The Plan denied your request. The Plan says there is no evidence that the prescribing physician saw the member.

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 back brace. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence on an objective physical exam by the member's treating medical provider that the member's pain is reduced by restricting mobility of the trunk; that the member requires the brace to facilitate healing following an injury to the spine or related soft tissues; or to facilitate healing following a surgical procedure on the spine or related soft tissue; or to support weak spinal muscles and/or a deformed spine.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 back brace have not been met.Therefore, we decided that the Plan does not have to pay forthe back brace (L0650) provided on September 12, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay forpositron emission tomography (PET) scan provided to the enrollee on March 9, 2020 and billed under code 78815-26-PI.You asked the Plan to pay forthis imaging. You say that this service should be covered by the Plan.The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial stating the PET scan was medically necessary. The Plan requested a reopen and stated the issue was not medical necessity but that the claim itself was not billed appropriately. The Plan says that denied  becauseit was not reported with an appropriate diagnosis. The Plan states the claim billed with diagnosis C10.9 -Malignant neoplasm of oropharynx, unspecified. The Medicare Claims Processing Manual, Chapter 13, Section 60.1, states "Claims for PET scan services must be billed using the ASC X12 837 professional claim format or on Form-CMS 1500 with the appropriate HCPCS or CPT code and diagnosis codes to the A/B MAC (B)."According to the National Coverage Determination (NCD) for Positron Emission Tomography (FDG) for Oncologic Conditions (220.6.17),  shows that diagnosis code C10.9 is not listed as an appropriate diagnosis code. Based on this CMS guidance, claims must be billed with an appropriate CPT and diagnosis code. The Planis correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the claim denied due to the omission of an appropriate diagnosis code. Medicare rules for coverage of this claim as billed have not been met.Therefore, we decided that the Plan does not have to pay forpositron emission tomography (PET) scan provided to the enrollee on March 9, 2020 and billed under code 78815-26-PI.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveintracardiac catheter ablation for atrial fibrillation.You asked the Plan to pre-approvethe cardiac ablation. You say that this procedure is urgently needed to treat the enrollee's condition.The Plan denied your request. The Plan says use of ablation for chronic atrial fibrillation is not supported by evidence in the literature as improving health outcomes and, therefore, is considered not medically necessary.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 cardiac ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a male with a history of hypertension, hyperlipidemia, diabetes, coronary disease, reduced ventricular function, chronic atrial fibrillation on anticoagulation and biventricular pacemaker placed in November 2020. Based on the records the patient has chronic persistent atrial fibrillation without symptoms, with good rate control and tolerating anticoagulation.In this circumstance the records do not support themedical necessity for an atrial fibrillation ablation procedure. Moreover, there is no documented attempt at restoring normal sinus rhythm with antiarrhythmic therapy plus cardioversion and the likelihood of maintaining normal sinus rhythm in this settingof chronic persistent atrial fibrillation is low with ablation.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 cardiac ablation have not been met.Therefore, we decided that the Plan does not have to pre-approveintracardiac catheter ablation for atrial fibrillation.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay fora computed tomography (CT) scan provided on May 29, 2020. You asked the Plan to pay forthis service. You say that these services should be paid by the Plan.The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that this claim denied because this service was previously paid to a provider of the same group on a different claim. The NPI website shows both providers are of the same practice group. The Plan states that the claim denied should have been included modifier  59,which  is  used  to  distinguish separate and distinct services. 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 and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met.Therefore, we decided that the Plan does not have to pay fora computed tomography (CT) scan provided on May 29, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay forcomputed tomography (CT) of the head or brain (70450) provided on May 13, 2020.You asked the Plan to pay forthis claim as billed. You say that this service should be covered by the Plan.The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says this claim denied because the provider billed with an inappropriate modifier. The Plan says that code70450 was billed with modifier26 in error. The Plan states the provider should have billed with modifier 59 to show a separate and distinct service. The Plan states this service was previously paid to another provider of the same practice 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, onlyone 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 and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met.Therefore, we decided that the Plan does not have to pay forcomputed tomography (CT) of the head or brain (70450) provided on May 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.

You asked the Plan to pre-approvethe LTACH services. You say that an LTACH level of care is needed due to the high flow oxygen. You say that no skilled nursing facility could provide the high flow. You say that the hospital has limited ICU/COVID-19 beds.The Plan denied your request. The Plan says LTACH care 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 there is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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-approvelong term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve a skilled nursing facility (SNF) admission. 
 
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 that the admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 
above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the admission is 
medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on December 23, 2020 after 
a stroke affecting her right side. She was discharged to the inpatient rehabilitation facility on January 4, 2021 for 
intensive therapy. On January 28, 2021 she required maximum assistance for upper body dressing and was dependent for 
lower body dressing. She has no skilled nursing needs. She has skilled therapy needs and requires skilled therapy on a 
daily basis. As a practical matter, the enrollee requires the necessary services on an inpatient basis at the SNF level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of these services 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 pre-approve a skilled nursing facility (SNF) admission.  
 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the endoscopy services provided on September 8, 2020.
You asked the Plan to waive the copay for the services provided. You say that services with your specialist only cost $50. The Plan denied your request. The Plan says the copay cannot be waived or reduced.
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 $450 copay for outpatient surgery in an outpatient hospital facility. You have been asked to pay a $450 copay for the endoscopy services. The services fall within the outpatient surgery 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 copay for the endoscopy services provided on September 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on October 12, 2020.
You asked the Plan to waive the copayment for the outpatient surgery. You say that this amount is very excessive for the procedure. You say the $395 should be partially paid for by your insurance. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $395 copayment per visit for in-network outpatient surgery. You have been asked to pay a $395 copayment for the outpatient surgery. The outpatient surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 the outpatient surgery provided on October 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Hyaluronan injection provided on October 27, 2020.
You asked the Plan to waive the coinsurance for the Hyaluronan injection. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a Hyaluronan injection on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.
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 20% coinsurance for Medicare Part B prescription drugs. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a Hyaluronan injection on October 27, 2020. You have been asked to pay a 20% coinsurance for the Hyaluronan injection, totaling $413.40. The Hyaluronan injection falls within the Medicare Part B prescription drugs 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 for the Hyaluronan injection provided on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on March 21, 2019.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the claim was not filed timely per Medicare guidelines.
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 physician services was not filed until August 26, 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 physician services provided on March 21, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided on April 24, 2019.You asked the Plan to pay forthe physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the claim was not submitted timely per Medicare guidelines.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 physician services was not filed until September 2, 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 forthe physician services provided on April 24, 2019
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveuse of Aranesp.You asked the Plan to pre-approveAranesp. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Retacrit before it will approve Aranesp.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 Aranesp. Our reviewer says that the enrollee does not meet the criteria for a step therapy exception for Aranesp. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drug of Retacrit. There is no documentation indicating that Retacrit would likely be less effective and/or likely have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met.Therefore, we decided that the Plan does not have to pre-approveuse of Aranesp
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe durable medical equipment provided on September 14, 2020.You asked the Plan to pay forthe durable medical equipment. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that when conducting a review of a covered DME item ordered by a physician, the Plan shall ensure that the physician saw the enrollee (including through the appropriate use of telehealth) and conducted a face-to-face assessment. We looked at the file and Medicare rules.The file does not contain documentation showing that the face-to-face encounter included information supporting the enrollee was evaluated or treated for a condition that supports the DME ordered. The file does not document that the face-to-face encounterwas made prior to the written order.Therefore, we decided that the Plan does not have to pay forthe durable medical equipment provided on September 14, 2020