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

We decided that the Plan does not have to pre-approve Remicade, 10 mg/kg every 4 weeks. You asked the Plan to pre-approve Remicade. You say that the enrollee has been on this medication since 2015. You say that when the enrollee was on 5mg/kg he was having a lot of problems. You say that the dose was increased to 10mg/kg every 4 weeks in 2016. You also say that the enrollee is currently stable and doing well on this dose. The Plan denied your request. The Plan says medications given for the treatment of a condition and exceed the frequency (how often you get an injection) or duration (how long you receive injections) that is indicated by accepted standards of medical practice are not covered. The Plan also says that the request for Remicade 10 mg/kg every 4 weeks exceeds what is indicated by accepted standards of medical practice for your condition.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Remicade. Our reviewer says that Remicade, 10 mg/kg every 4 weeks, is not medically necessary. Our physician reviewer found Remicade is covered under your medical benefit, but it requires approval first. The reviewer found that medications given for the treatment of a condition and exceed the frequency or duration that is indicated by accepted standards of medical practice are not covered. The reviewer found that the provided documentation shows that the request for Remicade 10 mg/kg every 4 weeks exceeds what is indicated by accepted standards of medical practice for the enrollee's condition. The reviewer found that the requested use/dose of Remicade is not FDA-approved for the enrollee's diagnosis. The reviewer found that the use in this case is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the reviewer found that Remicade, 10 mg/kg every 4 weeks, is not medically reasonable or 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 Remicade have not been met. Therefore, we decided that the Plan does not have to pre-approve Remicade, 10 mg/kg every 4 weeks.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a trigger point injection (CPT 20552) provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says procedure code 20552 is not a bilateral procedure.

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 20552 is "injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)."

We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found CPT 20552 trigger points are by muscle(s) injected; therefore, these codes are not reported bilaterally with a 50 modifier or with an RT/LT modifier. Reporting should be by number of muscles injected. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for a trigger point injection (CPT 20552) provided to the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services.

You asked the Plan to pay for the SNF services. You say that the services that were provided are coverable under the Medicare Act. The Plan denied your request. The Plan says the continued stay is not medically necessary. The Plan says that the enrollee reached his highest level of functional improvement and therefore the therapies were discontinued.

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 pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right L4-5 foraminotomy for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there was no record six-week non-operative therapy post-surgery.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not show that the enrollee has had adequate conservative measures to include a 6 week trial and failure of PT for back pain. There are no red flags for surgery at this time. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a right L4-5 foraminotomy for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).

You asked the Plan to pre-approve the complete mandibular denture. You say that you received a bottom partial denture but it did not fit right. You also say that you were fitted for a new denture but the service was denied because you had recently gotten a denture. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.

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, complete mandibular denture (D5120) is limited to one procedure every five plan years. The record shows that you received a complete mandibular denture (D5120) and your complete mandibular denture (D5120) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210).

You asked the Plan to pay for the dental services. You say that there are not any dentists that accept Medicare
within a 55 mile radius of your home. The Plan denied your request. The Plan says the provider in this case has
opted out of Medicare. The Plan also says that payment cannot be made to providers who have opted out of
Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the
extraction (D7210).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the intubation (31500) and ultrasound (76604).

You asked the Plan to pay for the intubation and ultrasound. You say that you would like reconsideration based on the records submitted, The Plan denied your request. The Plan says the documentation submitted does not support the services billed.

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 31500 is intubation, endotracheal, emergency procedure. 

The CPT Code Manual definition of code 76604 is ultrasound, chest (includes mediastinum), real time with image documentation.

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 intubation and ultrasound. Our reviewer says that CPT code 31500 does not meet criteria for billing or reimbursement consideration. The medical records submitted do not include sufficient documentation to validate that an Intubation, endotracheal, emergency procedure was performed, therefore this service cannot be verified. Our reviewer found CPT code 76004 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include sufficient documentation to validate that an Ultrasound, chest (includes mediastinum), real time with image documentation was performed, therefore this service cannot be verified.

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 intubation and ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the intubation (31500) and ultrasound (76604).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure.

You asked the Plan to pay for the unlisted neurological or neuromuscular diagnostic procedure. 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 payable.

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 95999 is unlisted neurological or neuromuscular diagnostic procedure. 

We find that CPT code 95999 is not supported in the medical record. Specifically, this service is considered a bundled procedure as the cost is included in the cost of the primary procedure. This code is not separately payable. Based on this information, we decided that Medicare rules for coverage of the unlisted neurological or neuromuscular diagnostic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiogram.

You asked the Plan to waive the copayment for these services. You say that you shouldn't be liable. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for each Medicare-covered diagnostic procedure and test in an in-network outpatient hospital facility.

Review of the file shows that you had an echocardiogram. You have been asked to pay a $100 copayment for these services. These services fall within the Medicare-covered diagnostic procedure and test in an in-network outpatient hospital facility 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 echocardiogram.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable control system.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee's upper limb strength and function are adequate for the enrollee to control the power options using their own switches.

The Plan follows Medicare rules. Medicare rules say wheelchair options and accessories are only covered under certain medical indications.

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 services. Our physician reviewer found that the enrollee has a 4 out of 5 right upper limb strength, except for right hand strength, which is 5 out of 5. The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant control. The enrollee's upper extremity function and strength are sufficient for this patient to operate any power options through their own switches.

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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable control system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Paclitaxel.

You asked the Plan to pre-approve Paclitaxel. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this drug is not reasonable and necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Paclitaxel. Our reviewer says that this service is not medically reasonable and necessary. Our physician reviewer found the combnation of Paclitaxel with Trastuzumab and Pertuzumab as proposed in this member would not be a standard regimen for early stage HER2 positive breast cancer. That combination is not FDA approved or supported by major drug compendia or the medical literature. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Paclitaxel have not been met. Therefore, we decided that the Plan does not have to pre-approve Paclitaxel.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided an out of network provider.

You asked the Plan to pay for the physician services. You say that the doctor should not be penalized for the facility's failure to obtain authorization. The Plan denied your request. The Plan says you did not request prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the physician services provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for wound care supplies.

You asked the Plan to waive the coinsurance for medical supplies. You say that you asked to be called before
any shipments so you could verify the cost, but you were not told about the charge for this order. The Plan
denied your request. The Plan says the coinsurance amount you are being charged is correct.

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 20%
coinsurance for in-network medical supplies. The allowed amount of the claim is $1,110, resulting in a
coinsurance obligation of $222.

You have been asked to pay 20% coinsurance for medical supplies. Medical supplies fall within the Durable
Medical Equipment (DME) and Related Supplies 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 wound care supplies.

Your complaint regarding not being told about the cost-share for these supplies is considered to be a grievance.
Maximus Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for
more information about your grievance.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided a participating.

You asked the Plan to waive the copayment for a CT scan. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $225 copayment for outpatient diagnostic tests/in-network/advanced imaging service. 

You have been asked to pay a $225 copayment for a CT scan. The correct copayment has been applied to the services that were provided. A CT scan falls within the outpatient diagnostic tests/in-network/advanced imaging service 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 a CT scan provided by a participating.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occupational therapy services to be provided by a provider outside of your medical group.

You asked the Plan to pre-approve the out-of-group services. You say that you feel that the requested provider is the only one in the plan who has any expertise with treating lipedema which you have been recently diagnosed with. You do not feel that physical therapy with a provider who does not have specialized knowledge of your condition would be helpful for you. The Plan denied your request. The Plan says you have recently consulted with a physical therapist with the qualification to treat your condition. You have started a treatment plan for this condition.

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 within your medical group. The Plan has providers within your medical group available who can provide the items/services at issue in this appeal. There is no evidence that you have completed a course of treatment with a network provider for your condition. If the course of treatment with this in-group provider fails, then a request for outside referral could be requested. We found no exception that would require the Plan to pre-approve these items/services at this time. Therefore, we decided that the Plan does not have to pre-approve occupational therapy services to be provided by a provider outside of your medical group.