Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine (90471, 90750).

You asked the Plan to pay for the shingles vaccine. You say that you would like reconsideration because your doctor told you this service was covered. The Plan denied your request. The Plan says the shingles shot is only covered under the Part D Prescription Drug benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90471, 90750).

Benefits for the shingles vaccine 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
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 pre-approve inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The enrollee is medically stable and has been provided medical clearance to undergo an elective right hip replacement. The planned procedure listed under CPT code 27130 is not listed on the CMS Inpatient Only List. The arthroplasty procedure is currently approved as an ambulatory outpatient procedure and there is no specific clinical rationale for an inpatient admission for the procedure. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of facet joint nerves (64635, 64640).
You asked the Plan to pre-approve radiofrequency ablation of facet joint nerves. You say that the enrollee had more than 80% relief from the first injection. The Plan denied your request. The Plan says two MBBs are required before the requested services can be approved.
The Plan must follow Medicare rules. Medicare rules say that only when dual medial branch blocks (MBBs) provide at least 80% relief of the primary or index pain and duration of relief is consistent with the agent employed may facet joint denervation with radiofrequency medial branch neurotomy be considered. We looked at the file and Medicare rules. The results of a second MBB are not included in the submitted medical records. Without this information, the medical necessity of the requested services cannot be verified. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation of facet joint nerves have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of facet joint nerves (64635, 64640).
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for lethargy, hypotension and falls. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care.
You asked the Plan to pre-approve continued inpatient psychiatric care. 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 inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient psychiatric care.
Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon
review of the records provided, the enrollee does not meet the criteria for continued acute inpatient mental
health treatment for the dates in question of April 9, 2021, forward as this enrollee was not shown to be a
danger to herself or others. She was not showing any auditory or visual hallucinations and was
cooperative/compliant with treatment while not showing any threats the safety.
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 inpatient psychiatric care have not been met. Therefore, we decided
that the Plan does not have to pre-approve continued inpatient psychiatric care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a nerve conduction study.

You asked the Plan to waive the copayment for a nerve conduction study. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 a $30 copayment for non-radiological diagnostic services.

You have been asked to pay a $30 copayment for a nerve conduction study. A nerve conduction study falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for a nerve conduction study.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services.

You asked the Plan to pay for the services provided. You say that payment is based on the presenting complaint and overall care. The Plan denied your request. The Plan says the documentation does not support the evaluation and management level as reported on the claim.

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 99285 is emergency department visit for the evaluation and management of a patient. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.

The file shows that the enrollee presented to the emergency room with an altered mental status. He was treated for a urinary tract infection. We find that CPT code 99285 is not supported in the medical record. Specifically, the records do not show that the presenting problem was of high severity. The records do not indicate the enrollee's condition posed an immediate threat to life or physiologic function. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to further pay for the emergency room services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-chiropractic services.

You asked the Plan to pay for the services provided. You say that you did get relief from the treatments. The Plan denied your request. The Plan says the only covered chiropractic services is manual manipulation of the spine to correct subluxation.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The file shows that you received office visits, electrical stimulation, and ultrasounds from a chiropractor. These services, when provided by a chiropractor, are not a covered benefit. Therefore, we decided that the Plan does not have to pay for the non-chiropractic services.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 enrollee was admitted for lower extremity cellulitis, aspiration pneumonia, respiratory failure and encephalopathy. The enrollee's medical problems are stable. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electrical stimulation (G0283) and manual traction therapy (97012) to be provided by a chiropractor.
You asked the Plan to pre-approve electrical stimulation and manual traction therapy. You say that the enrollee needs these services. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve electrical stimulation (G0283) and manual traction therapy (97012) to be provided by a chiropractor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says as this is going to be self-administered, this can be approved under Part D.
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 pre-approve Prolia.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for minimally invasive surgery for pleural effusion and lung nodules. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing services provided to the enrollee on February 13, 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 Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim was denied because the provider was not eligible for payment of this service. The NPI Registry website shows this provider is registered with a taxonomy for a Nurse Practitioner. However, the provider did not bill with this taxonomy. The Plan provided the additional claim pages that show the provider has billed with a Registered Nurse taxonomy. Medicare billing criteria are not met.
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 due to an issue with the taxonomy billed. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for nursing services provided to the enrollee on February 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you are concerned that if the enrollee does not go to acute rehab that he will have difficulty attaining his prior level of function and given that he will tolerate acute rehab, per physical therapy (PT) records. you believe that IRF is the most appropriate setting as opposed to SAR. The Plan denied your request. The Plan says an IRF admission 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 was admitted for COVID 19 infection and an iliopsoas abscess and discitis. The 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.

You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 a Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex spacer is experimental. More research is needed to show safety and efficacy of the device.

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 Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient radiology quantitative calcium scoring to be
billed as 75571.
You asked the Plan to pre-approve outpatient radiology quantitative calcium scoring. You say that you would
like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are
not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically 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 outpatient radiology quantitative
calcium scoring. Our reviewer says that the documentation does not support that the requested services are
medically reasonable or necessary. Our physician reviewer found the enrollee has already had a recent nuclear
stress test which is positive for cardiac ischemia. Next steps may include medical management or assessment of
coronary artery anatomy based on clinical factors. In any event, lipids and other cardiac risk factors should be
managed aggressively based on lab results. Quantification of coronary artery calcium with CT calcium scoring
at this point would therefore not affect further management. Therefore, the enrollee does not meet criteria for
the requested 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 outpatient radiology quantitative calcium scoring have not been met. Therefore,
we decided that the Plan does not have to pre-approve outpatient radiology quantitative calcium scoring to be
billed as 75571.