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

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee still needs these services. The Plan denied your request. The Plan says that the enrollee no longer requires daily skilled services and the continuation of SNF is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the compression supplies provided from September 30, 2020, to October 31, 2020.
You asked the Plan to waive the coinsurance for the compression supplies. You say that the coinsurance you are being asked to pay is too high. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for in-network Medicare-covered benefits for durable medical equipment. You have been asked to pay a total of $68.60 which is 20% of the allowed amount for the compression supplies. The total allowed amount is $343. ($343 x 20% = $68.60). The compression 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 the compression supplies provided from September 30, 2020, to October 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception for lower cost payment for out-of-network (OON) services for hemodialysis (CPT code 90937).
You asked the Plan to pre-approve the services. You say that you need in home dialysis and the facility is one of the only in home providers in the area. The Plan denied your request. The Plan says your condition did not meet the Medicare rules for pre-service approval of Preferred Provider Organization (PPO) exception (waiver) for lower cost payment from an out-of-network service. The Plan state you or your provider asked for routine (non-emergent) dialysis services. The Plan states they have dialysis providers (doctors and facilities) that can give you services at a lower cost. The Plan states these providers are called in-network providers.
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. Your diagnosis is kidney failure. The record sent by your provider indicates you need routine dialysis for your kidney failure to be supplied on a non-emergent basis. There are in-network providers in your area, and you do not need emergency care. If you want to pay a lower cost, you must receive your care from an in-network provider. You can find a list of in-network providers in your Provider Directory. Therefore, we decided that the Plan does not have to pre-approve an exception for lower cost payment for out-of-network (OON) services for hemodialysis (CPT code 90937).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement insulin pump (CPT code E0784).
You asked the Plan to pre-approve the pump. You say that your current pump you are using has been having technical issues. The Plan denied your request. The Plan says there is no mention of your pump failing or malfunctioning nor is the pump five (5) years old or greater. The Plan states a replacement pump is not necessary at this time.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump have not been met. Based on the warranty expiration date of February 10, 2021, and a warranty length of four (4) years, your pump's reasonable useful lifetime, minimally 5 years, has not been met. Therefore, we decided that the Plan does not have to pre-approve replacement insulin pump (CPT code E0784).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-preferred brand of test strips.
You asked the Plan to pre-approve the non-preferred brand of test strips. You say that you want to continue to use the requested brand of test strips. The Plan denied your request. The Plan says the requested brand of test strips is not the Plan's preferred brand.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no medical reason documented that the requested brand of test strips is medically necessary to avoid an adverse reaction. Based on this information, we decided that Medicare rules for coverage of test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the non-preferred brand of test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that this service is medically
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of
the pneumatic compression device have not been met.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device
(E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an aflibercept injection (J0178) provided on July 27, 2020.
You asked the Plan to waive the coinsurance for the drug injection. You say that you did not have a copayment for this service/drug when you had it earlier in the year. The Plan denied your request. The Plan says Part B drugs require 20% coinsurance. The Plan also states that the previous date of service where no cost-sharing was assessed was processed in error.
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 Medicare Part B Prescription Drugs. You have been asked to pay $372.71 for the drug injection. The Plan's allowed amount for this service is $1,863.54 ($1,863.54 x 20% coinsurance = $372.71). An aflibercept injection falls within the Medicare Part B Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an aflibercept injection (J0178) provided on July 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two additional crowns (for four crowns total) (D2750).
You asked the Plan to pre-approve the crowns. You say that these services are medically necessary. The Plan denied your request. The Plan says only two crowns may be covered per calendar year. Two crowns have already been approved, so the additional two cannot be provided.
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 crowns are requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two additional crowns (for four crowns total) (D2750).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections.

You asked the Plan to pre-approve Botox. You say that there is no documentation in the medical literature to
support the requested use. The Plan denied your request. The Plan says the enrollee has severe gastroparesis,
and options are limited.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
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 Botox. Our physician reviewer found
that the requested use of Botox is not FDA-approved for the enrollee's diagnosis. The use is not supported by
one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.
Although trials evaluating the effect of intrapyloric botulinum toxin injection on gastroparesis have been
reported, there is no agreement whether botulinum toxin can effectively relieve the symptoms and improve the
results of gastric emptying study in patients with gastroparesis. The documentation does not support that the
requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to
pre-approve Botox injections.
Appeal type: Testing
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided out of network on August 17, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and provided additional information.

The Plan is correct in this case. 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records submitted with the claim do not confirm these services were urgent or emergent. Therefore, we decided that the Plan does not have to pay for physician services provided out of network on August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on December 16, 2020.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service is not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on December 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 that the enrollee is a 67-year-old man who was admitted to an acute care hospital for
multiple injuries sustained in a motorcycle crash. The orthopedic injuries have been repaired and the wound
vac removed. The enrollee continues to receive ongoing acute care services that have not been denied. The
medical record does not indicate that the enrollee requires services which he is not currently receiving and
which the LTACH could provide. The elements of the coverage rule are not satisfied.
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 LTACH services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Home Health Private Duty Nursing (CPT code(s): S9123, and S9124).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services of a private duty nurse or other private duty attendant are not covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The services are not covered by your health plan or Medicare. Medicare guidance says status code "I" Not valid for Medicare purposes. Medicare uses another code for reporting of and payment for these services. Therefore, we decided that the Plan does not have to pre-approve Home Health Private Duty Nursing (CPT code(s): S9123, and S9124).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 14, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because this service was medically necessary. The Plan denied your request. The Plan says predictive screening is not a Medicare covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.
The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the submitted documentation does not include clinical information to verify why this testing was ordered or if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (22585, 22853) provided on November 16, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified
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 22585 is "Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)". The CPT Code Manual Definition of code 22853 is "Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)". 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 use of CPT codes 22585 and 22853 is not supported by the records provided. Our coding reviewer found that the operative report does not support CPT 22585 as a distinct procedural service (modifier 59), therefore, this code with modifier 59 cannot be supported. CPT 22853 was reported with 4 units. The documentation supports two units, therefore, four units 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 services have not been met. Therefore, we decided that the Plan does not
have to pay for the services (22585, 22853) provided on November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture provided from May 4, 2020, to October 8, 2020.
You asked the Plan to pay for acupuncture. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says these services are not a covered benefit. Maximus overturned the denial stating you used a Plan provider, and therefore these services should be covered. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
The Plan is correct in this case. Acupuncture is a supplemental benefit. The Medicare rules state that if a service is never covered by the plan and the Plan's Evidence of Coverage (EOC) is clear that the service or item is never covered, the Plan does not have to hold the enrollee harmless. The Plan contract clearly shows that acupuncture is not covered under any condition. Your Plan contract services as prior notice that these services were not covered. Therefore, we decided that the Plan does not have to pay for acupuncture provided from May 4, 2020, to October 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing G0483)provided to the enrollee on June 12, 2020 and billed under claim 820201900025851.
You asked the Plan to pay for this service. You say that this testing should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and submitted additional information. The Plan says that provider billed this service inappropriately. The records do not include definitive laboratory results for 22 or more drug classes to support the coding criteria for the code billed on date of service. There was only a total of 10 drug classes counted from the laboratory results received. Therefore, the code used cannot be paid.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due to an error with the code reported. The code reported indicated 22 or more drug classes were reviewed. The medical records show only 10 drug classes were reviewed. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided to the enrollee on June 12, 2020.