Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home health skilled nursing services (G0299x2, G0300x8).
You asked the Plan to pre-approve the home health services. You say that the enrollee has an open wound that needs care immediately. The Plan denied your request. The Plan says the services requested are custodial in nature and is not covered under Medicare.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 home health services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on review of the available records, the enrollee does not meet the CMS coverage criteria for any home health services. She is stable medically with debility and back pain. There are no documented daily skilled nursing needs. The enrollee has no IV medications and does not need any wound care or any care that involves skilled nursing services. Documentation does not support the need for HH services. Not medically necessary or reasonable. The enrollee's care needs can safely be addressed in a LTC facility with intermittent therapies as needed. 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve the home health skilled nursing services (G0299x2, G0300x8).
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve 8 additional home health skilled nursing visits.
You asked the Plan to pre-approve the additional home health visits. You say that you need the services due to you having a wound that needs to be changed 3 times a week. The Plan denied your request. The Plan says that the requested service is not medically necessary, and the enrollee does not meet the Medicare criteria for coverage.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 home health services. Our reviewer says that the Medicare criteria for continued Home Health aide coverage was met. Our physician reviewer found the documentation does support that the member requires skilled nursing services to provide treatment that is medically necessary. The enrollee does require skilled nursing to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has continued wounds that require monitoring by a skilled nurse. They continue to drain copious amounts of fluid and require compression dressing. He has also recently had a change in medication that he is being monitored for. The requested home health services are 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 home health services have been met. Therefore, we decided that the Plan has to pre-approve 8 additional home health skilled nursing visits. 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: Unfavorable

We decided that the Plan does not have to pay for the professional component for influenza (87804) and COVID-19 testing (U0003) provided on January 23, 2021.
You asked the Plan to pay for the professional component of codes 87804 and U0003. You say that the hospital required this testing, which led to the sample being sent to your office for processing. You believe that the Plan must pay for this service. The Plan denied your request. The Plan says the modifier used for these codes are not appropriate.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Modifier -26 denotes the professional component of physician services. This is used in the Physician Fee Schedule to report interpretation of diagnostic testing. However, codes 87804 and U0003 are not paid on the Physician Fee Schedule. These are paid on the Clinical Laboratory fee schedule which does not have a professional component for these codes. Based on this information, we decided that Medicare rules for coverage of the professional component of codes 87804 and U0003 have not been met. Therefore, we decided that the Plan does not have to pay for the professional component for influenza (87804) and COVID-19 testing (U0003) provided on January 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. You say that you do not have a driver's license and do not have a car and you cannot get into a transportation vehicle without a wheelchair lift. You say that you have one more ride left with appointments in September and October, which include a follow up visit, a specialist visit, and additional specialists throughout the year. You say that if you cannot get to these appointments, your health will be severely hindered. The Plan denied your request. The Plan says you have used 10 one-way transportation trips and are able to use 2 more one-way trips (1 round trip) for an upcoming doctor appointment. Once the 12 trips have been used, additional trips are not covered. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 12 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the hereditary cancer risk assessment provided on February 8, 2021.
You asked the Plan to pay for the cancer risk assessment. You say that this is medically necessary and ordered by the treating physician. The Plan denied your request. The Plan says that this is not coded correctly. The rules say that a single unit of 81479 must be used.
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 enrollee was referred for the cancer risk assessment by a contract provider. The file does not show that the plan provided notice that the cancer risk assessment would not be covered. The rules cited by the Plan regarding the codes used are not applicable to the State of Colorado where the services took place. Maximus was unable to find any specific rule which would prohibit billing as on this claim. Under Medicare rules, this means the cancer risk assessment is considered approved by the plan. Therefore, we decided that the Plan has to pay for the hereditary cancer risk assessment provided on February 8, 2021.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from February 5, 2021, through March 5, 2021.
You asked the Plan to pay for the SNF services provided from February 5, 2021, through March 5, 2021. You say that the SNF services were medically necessary. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient SNF level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services provided from
February 5, 2021, through March 5, 2021. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that the enrollee did not require any skilled nursing or rehabilitation services on a daily basis. He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care. The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved; however, his function had returned to baseline, and he did not require any further inpatient skilled nursing services. The enrollee's function was at or near his prior level of function and he could receive further services at a lower level of care. The enrollee required custodial services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services provided from February 5, 2021, through March 5, 2021 have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from February 5, 2021, through March 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional time increments of moderate sedation services provided on November 6, 2020, billed with code 99153.
You asked the Plan to pay for the services billed with 99153. You say that this should be paid. The Plan denied your request. The Plan says this is not payable in the outpatient hospital setting.
Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid in the facility setting. The Outpatient Prospective Payment System (OPPS) applies to all hospital outpatient departments. We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for the additional time increments of moderate sedation services provided on November 6, 2020, billed with code 99153.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you are disoriented and need assistance doing many daily functions. You say that you are a high risk for falling and you have no one to assist you at home. The Plan denied your request. The Plan says based on Medicare guidelines, the SNF services you and/or your provider are requesting do not meet the requirements for approval. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found from a nursing perspective; you have received oral medications. You had stable vital signs. You were treated for a urinary tract infection. Regarding rehabilitation services, you received physical therapy and occupational therapy. You were at a at a maximal assist to dependent level with functional mobility. You required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. As a practical matter, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services on January 31, 2021.
You asked the Plan to pay for the lab services. You say that these tests were necessary. The Plan denied your
request. The Plan says he records did not clearly indicate that the member presentation with a condition to
warrant the 81404, 81405 and 81406 performed.
The Plan follows Medicare rules. The rules say that coverage for the codes billed must meet Medicare criteria
for coverage and necessity. The records indicated the member required testing due to a diagnosis of Z80.3 -
family history of cancer. This is not a covered indication for CPT 81432, and coverage guidelines for this
procedure have not been met. Next, CPT codes 81295 and 81298 are included in the payment for CPT code
81432, which was billed on the same day. Lastly, the records did not clearly indicate that the member
presentation with a condition to warrant the 81404, 81405 and 81406 performed. Screening services such as
pre-symptomatic genetic tests and services used to detect an undiagnosed disease or disease predisposition are
not a Medicare benefit and are not covered. Therefore, the services as described above did not meet coverage
guidelines and are upheld. Therefore, we decided that the Plan does not have to pay for lab services on January
31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.

You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that the requested device would be used in a BiPAP mode that could be provided with a BiPAP.

The Plan must follow Medicare rules. The rules 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 a portable ventilator. Our reviewer says that a portable ventilator is not medically reasonable and necessary. You have chronic respiratory failure. There is no documented failure of BiPAP with backup respiratory rate and volume assurance to support this request. Our physician reviewer found that your condition does not meet Medicare criteria for a portable ventilator.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the remaining hospital care provided from January 18, 2021, to January 23, 2021.
You asked the Plan to pay for subsequent hospital care (99233) and critical care (99291). You say that the Plan should pay this claim. The Plan denied your request. The Plan says they have insufficient documentation to corroborate the services.
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 99233 is Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; 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 patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. The CPT Code Manual definition of code 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99233 and 99291 are not supported in the medical record. Specifically, 99291 is a time-based code and the total time spent was not documented. Subsequent hospital care 99233 documentation for dates of service January 20, 2021, January 22, 2021 and January 23, 2021 was not submitted. Based on this information, we decided that Medicare rules for coverage of subsequent hospital care (99233) and critical care (99291) have not been met. Therefore, we decided that the Plan does not have to pay for the remaining hospital care provided from January 18, 2021, to January 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #8 and a core buildup, including any pins when required (D2950) for tooth #8.
You asked the Plan to pre-approve the crown and core buildup. You say that the enrollee has an old existing crown on tooth #8 that has fractured and is causing the enrollee pain. You also say that the enrollee needs a new crown that will fit properly and help prevent further damage and restore normal masticatory function to tooth #8. The Plan denied your request. The Plan says these services exceed the benefit allowance.
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, crown (D2750) and is limited to one of either codes D2740, D2750, D2751, D2752, D2753, D2783, D2790, D2791, D2792, or D2794 per 60 Month(s), and core buildup, including any pins when required (D2950) is limited to one of either codes D2950,
D2952, or D2954 once per tooth per 60 months. The record shows that the enrollee received a crown (D2750) on tooth #8 and a core buildup, including any pins when required (D2950) on tooth #8 on June 27, 2018 and the enrollee's crown (D2750) and core buildup, including any pins when required (D2950) benefits for tooth #8 have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth #8 and a core buildup, including any pins when required (D2950) for tooth #8.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Exogen Electrical Bone Growth Stimulator

You asked the Plan to pre-approve the electrical bone growth stimulator. You say that your surgeon says you are at risk for non-union. The Plan denied your request. The Plan says because non-union of the fracture has not been documented by a minimum of two sets of radiographs separated by a minimum of 90 days, Medicare criteria have not been met and denial decision is upheld.

The Plan must follow Medicare rules. Medicare rules say that nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical osteogenic stimulator. Serial radiographs must include a minimum of 2 sets of radiographs, each including multiple views of the fracture site, separated by a minimum of 90 days. 

The documentation contains a letter from your surgeon. This is insufficient documentation to show that criteria have been met. Radiographs would be needed to prove necessity. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electrical bone growth stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve Exogen Electrical Bone Growth Stimulator
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 the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does require physical therapy and occupational therapy services but based on the medical records provided the
patient does not require an intensive inpatient rehabilitation therapy program. Medically necessary services can
be provided in a different 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 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.