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

We decided that the Plan has to pay for nursing facility care (99309) provided July 26, 2019.
You asked the Plan to pay for the nursing facility care. You say that the provider is in-network and the services
were medically necessary. The Plan denied your request. The Plan says that the services were not authorized.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The information provided to the IRE by the plan notes that the provider is a
contract provider. The plan failed to provide any documentation to support the denial. The denial letter did not
explain why the claim was denied. Records provided to the IRE were limited to a payment summary and a
background data form. The plan did not provide a narrative or rationale for the denial. Therefore, we decided
that the Plan has to pay for nursing facility care (99309) provided July 26, 2019.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT angiography (70496).You asked the Plan to pre-approve the CT angiography. You say that you would like reconsideration because the member had a stroke and their artery is 100% blocked.The Plan denied your request. The Plan says records do not show results of a picture study using sound waves of the blood vessels in neck that show there is a 70% or greater blockage of the blood flow.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the CT angiography. Our reviewer says that there is no rationale submitted for performing a carotid CT when the results of the carotid ultrasound examination are available to direct therapy. Our physician reviewer found CT Scan of the carotid arteries is not medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT angiography have not been met.Therefore, we decided that the Plan does not have to pre-approveCT angiography (70496).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lenses (V2781) purchased December 19, 2019.You asked the Plan to pay for the vision services. You say that before purchasing glasses you called to confirm glasses are covered after cataract surgery. The provider's staff did not know how to fill out claim benefit form so you paid on your credit card.The Plan denied your request. The Plan says this is not covered under the plan benefits.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 when covered eyeglasses after cataract surgery includes standard frames and lenses. Any upgrades are not covered including, but not limited to deluxe frames, tinting, progressive lenses or anti-reflective coating. We looked at the file and the Plan's rules. Upgrades are not covered. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay for the progressive lenses (V2781) purchased December 19, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room Visit (99281) on March 10, 2020.You asked the Plan to waive the copayment for the Emergency Room Visit. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct cost sharing was applied.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. You have been asked to pay a $90 copayment for the Emergency Room Visit. The Emergency Room Visit falls within the Emergency Care 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 an Emergency Room Visit (99281) on March 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stiolto.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 Stiolto.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing.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 enrollee does not meet the criteria for coverage.The Plan must follow Medicare rules. Medicare rules say that BRCA testing is covered when specific criteria are met.We looked at the file and Medicare rules. The records show that the enrollee does not have a personal history of cancer for which BRCA testing is covered. 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 BRCA genetic testing.
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 these services are medically necessary. The Plan denied your request. The Plan says that there is no clinical advantage of the inpatient rehabilitation facility care over the acute hospital.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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. You are medically stable with no evidence of need for supervision by physical medicine and rehab Physician or need acute rehab nursing care. Functionally given your level now, you do not require IRF level of therapies. You may benefit from further physical therapy and occupational therapy but do not require an intensive therapy program. Our physician reviewer found that your 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit and advance care planning provided on October 22, 2019 by an OON provider.You asked the Plan to pay for the domiciliary or rest home visit and advance care planning. You say that the services rendered were medically necessary to ensure the enrollee's overall health and to monitor their current conditions.The Plan denied your request. The Plan says the treating provider is a non-network provider. The Plan also says that the enrollee was not referred by their primary care physician.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on October 20, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe domiciliary or rest home visit and advance care planning provided on October 22, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on May 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that no one told you that this doctor was not part of your specific plan. The Plan denied your request. The Plan says prior authorization was not obtained for these services. The Plan says that there are in-network providers available for these services
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 has network providers available who can provide the items/services at issue in this appeal. 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 physician services provided on May 1, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a Procrit injection (J0885) provided on January 30, 2020.You asked the Plan to pay for the Procrit injection. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the appropriate modifier is missing.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code J0885 is not supported in the record. Specifically, CPT code J0885 was submitted without the required EA, EB or EC modifier. Based on this information, we decided that Medicare rules for coverage of the Procrit injection have not been met.Therefore, we decided that the Plan does not have to pay fora Procrit injection (J0885) provided on January 30, 2020.We note that it appears a corrected claim was submitted directly to MAXIMUS during the review of this case. We cannot act on or process claim corrections. Corrected claim information may be submitted directly to the Plan for further review. We are only permitted to make a decision based on the claim information reviewed by the Plan for payment. Please submit any corrections or additional claim information directly to the Plan.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveper cutaneous vertebral augmentation (22514 and 22515).You asked the Plan to pre-approve the percutaneous vertebral augmentation. You say that you would like reconsideration because this service is medically necessary for the treatment of the member's condition.The Plan denied your request. The Plan says the records do not show that the member has had treatment for this type of pain.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the percutaneous vertebral augmentation. 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 bone marrow edema as required by the LCD.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 percutaneous vertebral augmentation have not been met.Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (22514 and 22515).
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 you disagree with the denial.The Plan denied your request. The Plan says the services are 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 above.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 medically necessary. Our physician reviewer found the records show that you were admitted to the hospital for surgery. Your medical diagnoses are stable and do not require ongoing inpatient management. You have no complex nursing or rehabilitation needs. You may benefit from further therapy but do not require an intensive therapy program in an IRF. There is no reasonable expectation that you would be able to fully participate in and benefit from the intensive rehab program in an IRF. The IRF services are not 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for practitioner visit. You say that your provider depends on the facility to verify eligibility and obtain authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring facility is also out-of-network with the Plan.
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 has network providers available who can provide the items/services at issue in this appeal. 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 the medical services provided on January 15, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel 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 not billed correctly.The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479.The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on March 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 7, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. 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 the drug testing services provided on October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the alginate dressing (A6196) foam dressing (A6209) conforming bandage (A6442) enteral feeding supply kit (B4035) enteral formula (B4152) enteral nutrition infusion pump (B9002) and Iv pole (E0776) provided November 19, 2019 to November 30, 2019.
You asked the Plan to pay for the wound supplies and enteral supplies. You say that these are outpatient supplies covered under the Medicare B benefits. The enrollee is not on a skilled stay at the facility. The claim was billed correctly. The Plan denied your request. The Plan says please correct OCE (outpatient code editor) edit error on other claim line. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan would accept a submission of a corrected claim to consider services for payment.
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 provider billed with CPT/HCPCS codes services and are identified in the OPPS Addendum B with a SI = Y - Non-implantable DME. Per Medicare guidelines the claim denied per Service Can Only be Billed to the DMERC. Based on this information, we decided that Medicare rules for coverage of the wound supplies and enteral supplies have not been met.
Therefore, we decided that the Plan does not have to pay for the alginate dressing (A6196) foam dressing (A6209) conforming bandage (A6442) enteral feeding supply kit (B4035) enteral formula (B4152) enteral nutrition infusion pump (B9002) and Iv pole (E0776) provided November 19, 2019 to November 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded G0483 provided on October 23, 2019.You asked the Plan topay forthe drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and(3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation did not include a valid physician order/lab requisition or medical records (signed by the ordering physician). Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing coded G0483 provided on October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prosthetic services to be provided by an out of network provider.
You asked the Plan to pre-approve the prosthetic services with an out of network provider. You say that you have been seeing this provider since 1963 and you should be able to continue using them. The Plan denied your request. The Plan says there are in network providers available to meet your needs.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the prosthetic services to be provided by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered by Part B.
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 for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.