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

We decided that the Plan does not have to pay for the drug testing services provided on April 14, 2020.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the
services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based
on this information, we decided that Medicare rules for coverage of the drug testing services have not been
met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on April
14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 has a past medical history of uterine cancer, COVID-19 infection, kidney cancer, atrial fibrillation and is living at home with ongoing weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on August 22, 2019.

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 procedure codes 95885, 95908, and 95999 are not supported.

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 95885 is needle electromyography, each extremity, with
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study;
limited (List separately in addition to code for primary procedure). The definition of code 95908 is nerve
conduction studies; 3-4 studies. The definition of code 95999 is unlisted neurological or neuromuscular
diagnostic procedure.

We find that CPT codes 95885, 95908, and 95999 are not supported in the medical record. Specifically, the
documentation does not include limited needle electromyography to support code 95885. There is no
documentation of 3-4 nerve conduction studies to support code 95908. There is no documentation of an
unlisted neurological or neuromuscular diagnostic procedure to support code 95999. 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 testing services rendered on August 22, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of tunneled central venous tube for infusion,
ultrasonic guidance for blood vessel access, fluoroscopic guidance for vein device, and moderate sedation
services provided on October 29, 2019.
You asked the Plan to pay for the insertion of tunneled central venous tube for infusion, ultrasonic guidance for
blood vessel access, fluoroscopic guidance for vein device, and moderate sedation services. You say that the
enrollee was not active under hospice on this date of service. The Plan denied your request. The Plan says
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to
the enrollee's terminal condition.
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 10, 2019. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the insertion of
tunneled central venous tube for infusion, ultrasonic guidance for blood vessel access, fluoroscopic guidance
for vein device, and moderate sedation services provided on October 29, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy and lab work provided by a participating provider on October 28, 2020.

You asked the Plan to waive the copayment for a diagnostic colonoscopy and lab work. You say that you were told that this was covered 100%. The Plan denied your request. The Plan says the correct copayments have 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 $250 copayment for outpatient surgery/in-network and a $10 copayment for outpatient diagnostic tests/in-network/labs. 

You have been asked to pay a $250 copayment for a diagnostic colonoscopy and $3.93 which is less than your copayment amount of $10 for a diagnostic colonoscopy and lab work. Evidence was provided to show that a polyp was found and removed. The rules say that, if during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed. a diagnostic colonoscopy and lab work falls within the outpatient surgery/in-network and outpatient diagnostic tests/in-network/labs 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 diagnostic colonoscopy and lab work provided by a participating provider on October 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from February 10, 2021, to February 11, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you should not be held responsible for this charge. The Plan denied your request. The Plan says Medicare Part B does not cover drugs that are usually self-administered by the enrollee.
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 pay for the self-administered drugs provided from February 10, 2021, to February 11, 2021.
Benefits for the self-administered drugs 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee has returned to prior baseline level of function.
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. Continued SNF services beyond May 17, 2021, were requested. 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 continued services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a supervision to contact guard assist level with functional mobility. She required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. She does not require skilled nursing or therapy services on a daily basis. She does not meet severity of illness or intensity of service criteria for 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Unfavorable

We decided the Plan does not have to pay for a duplex scan provided to the enrollee on September 11, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria.

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 code. In this case, based on the Medicare Local Coverage Article, for a diagnosis of I10, for accelerated hypertension the codes used are 93975, 93976, 93978, and 93979. Code 93970 is not among those listed as a covered code for this diagnosis. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for a duplex scan provided to the enrollee on September 11, 2020 and billed under code 93970 with diagnosis code I10 for Essential (primary) Hypertension.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services rendered on July 31, 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 procedure codes 78812, 74176, 70490, and 71250 are not supported.

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 codes 78812, 74176, 70490, and 71250 not supported in the medical record. Specifically, the submitted documentation does not contain a date of service. 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 imaging services rendered on July 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic consultation provided by a dentist or physician other than the treating dentist or physician (D9310) provided on January 11, 2021.

You asked the Plan to pay for the diagnostic consultation. You say that you do not understand why this consultation is denied for coverage and feel it is outrageous. The Plan denied your request. The Plan says some evaluations and exams are covered by the Plan, however the type of consultation you received is not listed as a covered service in your contract and therefore is excluded from coverage.

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 a diagnostic consultation provided by a dentist or physician other than the treating dentist or physician (D9310) provided on January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 14, 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 billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing
rendered on August 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical radiographic images (D0220, D0230 x3), and bitewing radiographic images (D0274) provided on December 1, 2020.

You asked the Plan to pay for intraoral periapical radiographic images, and bitewing radiographic images. You say that you thought these services were covered up to 3 times per year and you would like the plan to pay. The Plan denied your request. The Plan says the bitewing radiographic images are a covered benefit, but you have exceeded the frequency limit of one every year. The intraoral periapical radiographic images are not a covered benefit.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of intraoral periapical radiographic images, and bitewing radiographic images have not been met. Specifically, the record shows that you had exceeded the frequency limit for the bitewing radiographic images prior to this service on May 11, 2020. Additionally, intraoral periapical radiographic images are not a covered benefit. Therefore, we decided that the Plan does not have to pay for intraoral periapical radiographic images (D0220, D0230 x3), and bitewing radiographic images (D0274) provided on December 1, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to reimburse you the copayment for skilled nursing facility services from December 1, 2020, to December 11, 2020.

You asked the Plan to reimburse you the copayment for skilled nursing facility services. You say that you needed additional treatment before going home. The Plan denied your request. The Plan says you were charged the copayment correctly for days 21-25.

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 $178 copayment for each day 21 through 100 for Skilled Nursing Facility Care. 

You have been asked to pay a $178 copayment for days 21 through 25 for the skilled nursing facility services. The skilled nursing facility services fall within the Skilled Nursing Facility 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 reimburse you the copayment for skilled nursing facility services from December 1, 2020, to December 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epogen (J0885).

You asked the Plan to pre-approve Epogen. The Plan denied your request. The Plan says the enrollee does not meet the clinical criteria for coverage or the step therapy requirements.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Epogen. Our reviewer says that Epogen (J0885) is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the medical records provided the enrollee has not tried and failed the required drug, Retacrit. Our reviewer also found that there is no indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for the 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 Epogen have not been met. Therefore, we decided that the Plan does not have to pre-approve Epogen (J0885).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Intensity Modulated Radiation Therapy (IMRT).
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that there is not enough clinical support for 45 treatments.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. The file shows that 45 treatments of IMRT were requested. The Plan has agreed to pre-approve 28 treatments. 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 additional treatments. Our physician reviewer found that the enrollee has a diagnosis of adenocarcinoma of the prostate. It is documented that the enrollee falls into Grade Group 4 disease and has more aggressive histology and poor prognostic features. 45 treatments of IMRT have been requested. Conventional fractionation in greater than 40 fractions is an accepted standard of care, given the clinical setting for this enrollee. Therefore, the additional requested treatments of IMRT are medically reasonable and necessary to treat the 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 the requested services have been met. Therefore, we decided that the Plan has to pre-approve Intensity Modulated Radiation Therapy (IMRT).
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient PT.

You asked the Plan to pre-approve the outpatient PT. You say that you have Parkinson's disease and if you do not continue with physical therapy, you fear that you will lose your mobility. The Plan denied your request. The Plan says physical therapy is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 outpatient PT. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you are at your functional baseline and you have been independent with a home exercise program. The requested physical therapy sessions are considered excessive and not an appropriate duration and frequency for your medical condition. 

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 outpatient PT have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient PT.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on August 22, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. 

We looked at the file and Medicare rules. Per LCD L36129, the requested cardiovascular risk assessment testing is not covered. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on August 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available.

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 a referral to an out-of-network provider.