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

We decided that the Plan does not have to pre-approve Verquvo.
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 Verquvo. Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the biologic materials used to aid in tissue regeneration coded as D4265 along with other dental services provided on April 15, 2021.
You asked the Plan to pay for the biologic tissue regeneration materials (D4265). You say that you feel that some payment should be made toward D4265 since it was necessary to be done as part of the other services you received. The Plan denied your request. The Plan says the services provided under this code are not covered by your dental plan.
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 biologic materials used to aid in tissue regeneration coded as D4265 along with other dental services provided on April 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided on August 13, 2020, billed with code 99222-58.
You asked the Plan to pay for the services as billed. You say that a prior claim was denied for use of modifier -78, so this claim with modifier -58 was submitted. You believe that this modifier is appropriate and should be paid. The Plan denied your request. The Plan says this is not a correct modifier.
The Plan must follow Medicare rules. Medicare rules say that modifier -58 is used for billing of staged or related surgical procedure in the postoperative period. In this case, the service at issue is not a surgical procedure that was staged or related to a prior surgery. This is an evaluation and management (EM) service. Use of modifier -58 with EM services is not appropriate based on the definition of the modifier. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided on August 13, 2020, billed with code 99222-58.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira.
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 Humira.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you need to see this out-of-network provider because they take a "team approach." You say the in-network providers have not been able to help. The Plan denied your request. The Plan says the provider is out-of-network
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 an office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve heavy duty wheelchair.
You asked the Plan to pre-approve a manual wheelchair. You say that you were told not to take the power
scooter outside. The Plan denied your request. The Plan says Medicare does not provide two pieces of
equipment that serve the same purpose.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that you have heavy duty power scooter. A heavy-duty power scooter serves the same purpose
as the manual wheelchair. Therefore, we decided that the Plan does not have to pre-approve heavy duty
wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services from July 29, 2019 to August 3, 2019.
You asked the Plan to pay for the inpatient hospital services. You say that the coding is correct. The Plan denied your request. The Plan says the billed diagnosis code is not supported. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with I95.9. 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 inpatient hospital services. Our reviewer says that the billed diagnosis code is not supported. Our physician reviewer found the provider documented within the medical record including the discharge summary that the hypotension was likely due to dehydration. In accordance with OCG Section I.C.18.b the definitive diagnosis code should be sequenced before the symptom code. Consistent documentation throughout the medical record states the patient was dehydrated and the focus of care and thrust of treatment was to receive IV fluids. Coding and billing guidelines support assigning code E86.0, (Dehydration) as the principal diagnosis for reimbursement and this re-sequencing resulted in a change in DRG from 0315 to 0641. The use of primary diagnosis code I95.9 was not supported by the records provided. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services from July 29, 2019 to August 3, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services.
You asked the Plan to pay for the emergency room services. You say that the service should be covered as billed. The Plan denied your request. The Plan says the enrollee's visit does not meet the coding criteria.
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 an "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 coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the emergency room services. Our reviewer says that the coding does not meet criteria. Our reviewer found emergency room visit supports an Expanded Problem Focused History, Comprehensive Exam, and Medicare Decision Making of Low Complexity. Therefore, a more appropriate code to report for this service is CPT 99282. Therefore CPT 99285 would not be covered. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that the member has a 20-pack year smoking history. He recently quit smoking in 2019. You say that given his age (54-year-old), smoking history, and recent history of smoking cessation that he should undergo a screening lung CT. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above-described criteria. 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 requested LDCT scan. Our reviewer says that the requested LDCT scan is not considered medically reasonable and necessary in this case. Our physician reviewer found that a low-dose chest CT for lung cancer screening is not medically necessary for this enrollee. The enrollee is 54 years of age with a 20 pack-year smoking history. Medicare criteria for lung cancer screening are age 55 to 77 years of age, with at least 30 pack-years of smoking history. We looked at this physician's review, the file and the Medicare rules. We find that the Medicare rules for coverage of a LDCT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings for teeth #3 and 5 provided on May 12, 2021, and the filling for tooth #15 provided on May 26, 2021.
You asked the Plan to pay for these three additional fillings. You say that you were not aware that only two fillings per year are covered by the plan. If you knew this, you would have waited until you were financially able to cover this expense. You feel that some payment should be made. The Plan denied your request. The Plan says payment was made for two fillings. Additional fillings are not covered during the 2021 calendar year.
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, only two fillings can be covered per year. Therefore, we decided that the Plan does not have to pay for the fillings for teeth #3 and 5 provided on May 12, 2021, and the filling for tooth #15 provided on May 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a peri-auricular stimulation (P-Stim) device for the
enrollee.
You asked the Plan to pre-approve these services. You say that this is recommended to help decrease the
enrollee's pain. The Plan denied your request. The Plan says that this is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that auricular PNS is not covered by Medicare as it is
not considered medically reasonable and necessary. Therefore, we decided that the Plan does not have to preapprove
a peri-auricular stimulation (P-Stim) device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne Heme genetic panel provided on March 3, 2021, billed with code 81455.
You asked the Plan to pay for the FoundationOne Heme testing. You say that this is a Medicare-covered test and should be allowed for this enrollee's condition. The Plan denied your request. The Plan says genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. The Plan must follow Medicare rules. Medicare rules say that genomic sequence analysis panels for conditions such as acute leukemia may be considered medically reasonable and necessary. The code for this is 81450, for up to 50 genes. Code 81455 for more than 50 genes is not listed as covered in the rules. Although this testing may be considered medically necessary, the code 81455 is not correct for billing this testing. Therefore, we decided that the Plan does not have to pay for the FoundationOne Heme genetic panel provided on March 3, 2021, billed with code 81455.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two periodic oral evaluations, two cleanings, and two topical applications of fluoride.
You asked the Plan to pre-approve these services. You say that the services are necessary. The Plan denied your request. The Plan says the request exceeds the benefit limit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers two periodic exams per plan year, two cleanings per plan year, and two fluoride procedures per plan year. We looked at the file and the Plan's rules. The file shows that you have used the two periodic exams, two cleanings, and two fluoride procedures per Plan year. The Plan has also approved further prior services. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve two periodic oral evaluations, two cleanings, and two topical applications of fluoride.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections provided on March 31, 2021, billed with codes J3490 and 96372.
You asked the Plan to pay for the nutria-pharmaceutical injections. You say that this is billed correctly and should be paid. The Plan denied your request. The Plan says these services are not supported.
The Plan must follow Medicare rules. Medicare rules say that compounded drugs should be reported using the compounded drug, NOC code. The drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections provided on March 31, 2021, billed with codes J3490 and 96372.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the annual depression screening (G0444) provided on September 15, 2020.
You asked the Plan to pay for the annual depression screening. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this service cannot be verified because the amount of time spent rendering this service was not documented in the medical record.
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 G0444 is annual depression screening, 15 minutes. We find that CPT code G0444 is supported in the medical record. Specifically, the record clearly shows that the depression screening was rendered on the billed date of service. There is no ruling from Medicare or the governing Medicare Appeals Contractor requiring that the medical documentation includes the amount of time spent rendering this service. Based on this information, we decided that Medicare rules for coverage of the annual depression screening have been met. Therefore, we decided that the Plan has to pay for the annual depression screening (G0444) provided on September 15, 2020.
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: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pay for the neurology office visit (99211), multiple diagnostic tests (95912,
95923, 95937-59, 95925, 95927-59, 95886, and 95887). We decided that the Plan does not have to pay for the
medical supplies (A4558, A4556, A4215, and A4927).
You asked the Plan to pay for the neurology office visit (99211), multiple diagnostic tests (95912, 95923,
95937-59, 95925, 95927-59, 95886, and 95887). You say that these services were medically necessary and
should be paid. The Plan says that it has decided to process most of the codes at issue in your appeal as separate
cases that will not be sent to Maximus. Only two codes are being forwarded for independent review due to the
status indicator of "P".
We decided that the Plan has to pay for the neurology office visit (99211), multiple diagnostic tests
(95912, 95923, 95937-59, 95925, 95927-59, 95886, and 95887.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.
The case record and claim information indicates that the enrollee was referred for this evaluation and testing by
a contracted orthopedic surgeon. The file does not show that the plan provided notice that these services would
not be covered. There is no obvious defect in how these services were billed. Under Medicare rules, this means
these services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the
neurology office visit (99211), multiple diagnostic tests (95912, 95923, 95937-59, 95925, 95927-59, 95886,
and 95887.
We also decided that the Plan does not have to pay for the medical supplies (A4558, A4556, A4215, and
A4927).
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
Codes A4215 and A4927 have a status indicator of "X" on the Physician Fee Schedule. This means that they
are excluded from coverage on the fee schedule as they are not physician services. Codes A4556 and A4558
have a status indicator of "P". This means that no payment can be made for these items as payment is bundled
with the payment for the physician services provided on the same date. Therefore, we decided that the Plan
does not have to pay for the medical supplies (A4558, A4556, A4215, and A4927). 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the durable medical equipment to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the durable medical equipment. You say that you trust this provider and want to be under his care for foot surgery. The Plan denied your request. The Plan says the provider is out-of-network
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 durable medical equipment to be provided by an out-of-network (OON) provider.
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 LTACH Admission is medically
necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current
level of care.
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 documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the
current health care setting being offered by the health plan.
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.