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

We decided that the Plan does not have to pay for self-administered drugs (A9270) provided June 16, 2020 to June 17, 2020.
You asked the Plan to pay for the self-administered drugs. You say that the drugs should be covered. The Plan denied your request. The Plan says self-administered drugs are not covered under the Part B Medical Benefit.
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 self-administered drugs (A9270) provided June 16, 2020 to June 17, 2020.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network cost share for medical services to be provided by an out-of-network provider.
You asked the Plan to pre-approve an in-network exception. You say that you are the only occupational therapists that specialize in low vision rehab in the enrollee's home. The Plan denied your request. The Plan says there are in-network provider available who can provide the service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that if you use an out-of-network provider, your share of the costs for covered services may be higher. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The enrollee does have out-of-network benefits at a higher cost share. We found no exception that would require the Plan to pre-approve an in-network exception. Therefore, we decided that the Plan does not have to pre-approve an in-network cost share for medical services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99205) provided on June 10, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for an OON office visit. You say that this was medically necessary. The Plan denied
your request. The Plan says this was not authorized.
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 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. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the office visit (99205) provided on June 10, 2020
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eye refraction provided on September 3, 2020.You asked the Plan to pay forthe services provided. You say that the procedure was performed in conjunction with the enrollee'scataract surgeries.The Plan denied your request. The Plan says eye refraction is only covered when performed during an annual eye exam.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.We looked at the file and the Plan's rules. The records provided do not indicate the refraction services were provided during an annual routine eye exam.Based on this information, we decided that the Plan's rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay forthe eye refraction provided on September 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that you are not able to perform daily living
activities without risking another fall with further injury to your ribs. The Plan denied your request. The Plan
says your functional level is currently high enough that daily skilled therapy 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 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 pre-approve the SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 81-year-old
male with bladder cancer, "mini-stroke," a fall with rib fractures. From a nursing perspective, the beneficiary
received oral medications. The beneficiary had stable vital signs. He was treated for pain with effect. Regarding
rehabilitation services, the beneficiary received PT in the acute hospital. The beneficiary was at a minimal
assist to stand by assist level with functional mobility including gait to 250 feet.
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs;
however, the beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility
setting.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must followMedicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if thePlan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity ofservices provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a
participating provider on September 21, 2020.
You asked the Plan to waive the copayment for ambulance services. 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 $200
copayment for ambulance services.
You have been asked to pay a $200 copayment for ambulance services. Ambulance services fall within the
ambulance services 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 ambulance services
provided by a participating provider on September 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on May 21, 2020.You asked the Plan to pay forthese 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 forthe laboratory services rendered on May 21, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveCyramza.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services are not medically 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has large cell right upper lobe lung cancer with excision. Large cell lung cancer is a rare entity with features of both small cell and non-small cell lung cancer. There are not clear treatment guidelines and sequencing of therapy often follows both type of cancer. The use of Cyramza is FDA approved for the treatment (in combination with docetaxel) of metastatic non-small cell lung cancer in patients with disease progression on or after platinum-based chemotherapy. The plan is to use Cyramza in combnation with docetaxel. This enrollee meets the criteria for coverage. The service is reasonable and 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 these services have been met.Therefore, we decided that the Plan has to pre-approveCyramza.If the Plandoes 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 doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the shoulder x-ray rendered on September 3, 2020.
You asked the Plan to waive the copayment for these services. You say that the provider advised that the copayment was $200. 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 $350 copayment for x-rays performed at an outpatient hospital facility.
Review of the file shows that you received a shoulder x-ray on September 3, 2020 at an outpatient hospital facility. You have been asked to pay a $350 copayment for these services. These services fall within the x-rays performed at an 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 shoulder x-ray rendered on September 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 8, 2020 by a nonnetwork provider.
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 services were rendered by a non-network provider without 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 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. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on July 8, 2020 by a
non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forspecialist services provided on June 10, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forspecialist services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these services were not referred by a participating provider.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 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. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forspecialist services provided on June 10, 2020, by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services to be provided by an oral surgeon.You asked the Planto pre-approvethe dental services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis type of provider 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. The Plan covers dental services when provided by a participating general dentist.The plan does not cover these services when provided by anoral surgeon. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvedental services to be provided by an oral surgeon.
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 enrollee would benefit from intensive physical
and occupational therapy. The Plan denied your request. The Plan says the enrollee has mostly chronic
functional issues from previous stroke and is not likely to benefit from the IRF level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was
admitted for acute kidney injury. Medical conditions are stable. There are no medical needs requiring inpatient
admission. There are no complex nursing or rehabilitation needs. While the medical record documents a need
for physical and occupational therapy, it does not document a need for an intensive rehabilitation program.
There is not a reasonable expectation that this patient 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided March 23, 2020, to
March 24, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like this claim reprocessed
and approved for payment. The Plan denied your request. The Plan says the inpatient hospital care was not
medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found you presented to the emergency room on March 23, 2020, with chief complaints of
worsening shortness of breath, productive cough with yellow thick phlegm and subjective fever. Your
condition stabilized and improved, and you were discharged home on March 24, 2020. The review indicates
that the record did not show that at the time of inpatient admission the admitting physician reasonably expected
that your necessary hospital care (including earlier ED and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided March 23, 2020, to March 24, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 there are no services at the LTACH that theenrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed.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-approvelong term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Favorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on February 9,
2020 and billed under code 73110.
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 Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan
requested a reopen. The Plan says that Maximus has issued an overturn decision stating that the Plan must pay
this claim. It has been determined that this claim denied because the provider did not bill with the appropriate
modifier to show which side of the body the service was performed on. According to the Plans review, the
anatomic-specific modifiers LT (Left side), RT (Right side), and 50 (Bilateral procedure) designate the
area or part of the body on which the procedure is performed. These modifiers were not billed by the provider
and in this case were required. The Plan says that the Medicare Claims Processing Manual Chapter 4 Section
20.6.3 explains that Modifiers -LT or -RT apply to codes, which identify procedures, which can be
performed on paired body areas. The Plan says that modifiers -LT and -RT should be used whenever a
procedure is performed on only one side. These modifiers are required whenever they are appropriate.
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 and when required, the
appropriate modifiers. In this case, the claim submitted cannot be paid as billed due to the omission of the
required modifiers. Medicare rules for coverage of this service have not been met. Therefore, we decided that
the Plan does not have to pay for physician services provided to the enrollee on February 9, 2020 and billed
under code 73110.