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

We decided that the Plan does not have to pay for drug testing provided to the enrollee on August 7, 2019 and billed under code G0481.

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 stated that Maximus did not apply the correct LCD criteria. The Plan says that this is a billing error on the part of the provider. The Plan states the records do not contain documentation of definitive laboratory results for 8 to 14 drug classes, including metabolites to support the coding criteria for G0481. 

Our Medical Director looked at the case file and the reopen request. At issue is coverage for CPT code G0481 - Drug test(s), definitive, 8-14 classes. Maximus determined that the documentation submitted supports that drug testing was performed on 8 to 14 drug classes, including metabolites, and therefore Medicare coverage rules were met. However, the Plan is correct in this case. Based on the records provided, the Patient Test Results Summary documents results for 7 drug classes only. Therefore, Medicare LCD coverage criteria are not met. 
We looked at this physician's review, the file, and Medicare rules. 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 drug testing provided to the enrollee on August 7, 2019 and billed under code G0481.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D5110, D5120).You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis request exceeds the benefit limit of one procedure every five plan years.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 denture once every year.We looked at the file, and Medicare rules. Dentures were last received less than five years ago. Based on this information, we decided that the Plan's rules for coverage of the services have been met.Therefore, we decided that the Plandoes not haveto pre-approvedental services (D5110, D5120).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveXolair for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is not a history of urticaria for six months.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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the compendia support the use of Xolair for patients with chronic idiopathic urticaria "...in patients who remain symptomatic despite therapy with histamine H1-receptor antagonists." A progress note dates 1/14/21 indicates urticaria resolved with antihistamines. Medical necessity cannot be determined.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 drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveXolair for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home blood pressure monitor.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve a home blood pressure monitor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approveProlia. You say that you want the enrollee treated with this drug.The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to zoledronic acid.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan'scontract 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 Prolia. Our reviewer says that the drug is not reasonable and medically necessary. Our physician reviewer found based on the medical records provided the patient has not tried and failed the required drug(s). Based on the medical records provided there is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the patient. No, based on the medical records provided there is no documentation that the enrollee has a history of an osteoporosis related fracture.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia
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. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting.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 ifthe Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that the enrollee was admitted to the acute hospital due to a stroke. His hospitalization was complicated by acute kidney failure, respiratoryfailure and brain herniation. He remains ventilator dependent and obtunded. Hestill requires acute hospital level of care services,and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation system (E2300).You asked the Plan to pre-approvethe system. You say that this is medically necessary.The Plan denied your request. The Plan says this is not primarily medical in nature.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item atissue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea power seat elevation system (E2300)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate forthe panoramic x-ray (D0330) provided on July 1, 2020.You asked the Plan to pay the in network rate forthe panoramic x-ray. You say that you feel it is unfair to the doctor and yourself not to pay for the services. You say that you were referred by an in network doctor for the services. You also say that with your medical condition, you have to have teeth extracted at the hospital.The Plan denied your request. The Plan says 1 panoramic x-ray is covered every 5 years. The Plan also says that the frequency limit for this service has been exceeded.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 frequency limit of 1 panoramic x-ray every 5 yearshas been exceeded. The record shows that the Plan paid for a panoramic x-ray that you received o June 24, 2019, less than 5 years ago.Therefore, we decided that the Plan does not have to pay the in network rate forthe panoramic x-ray (D0330) provided on July 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe sacroiliac (SI) joint fusion surgery (27279).You asked the Plan to pre-approvethe sacroiliac joint fusion surgery. You say that this service is medically necessary.The Plan denied your request. The Plan says medical necessity guidelines 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 the sacroiliac joint fusion surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documented sacroiliac joint instability, fracture, or lesion. The medical records show that the patient has degenerative low back pain. Her MRI shows lumbar degeneration. Therefore, criteria have not been met.
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 sacroiliac joint fusion surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvethe sacroiliac (SI) joint fusion surgery (27279).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea 4K score assay test.You asked the Planto pre-approvethe test. You say that this is medically necessary.The Plandenied your request. The Plansaysthere are significant issues with assay validation and an absence of clinical utility.The Plan must follow Medicare rules. The rules say that there is no clinical utility to the 4Kscore assay test.The requested test is not yet covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the test have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea 4K score assay test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Volara system.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are notcovered. 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 not medically necessary. Our physician reviewer found the enrollee has bronchiectasis documented by computed tomography (CT) of the chest with a chronic productive cough and recurrent respiratory infections. She has tried the Acapella device without benefit and wasunable to tolerate HFCWOD therapy. The Volara system is a combination of positive end-expiratory pressure, airway oscillation, and nebulization of medication, delivered by mouthpiece or face mask. Its use has generally been for hospitalized patients. Efficacy in the chronic outpatient treatment of bronchiectasis has not been convincingly demonstrated. The services are therefore not 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 not been met.Therefore, we decided that the Plan does not have to pre-approvea Volara system.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOrthovisc.You asked the Plan to pre-approveOrthovisc. You say that without knee injections, your quality of life will be affected.The Plan denied your request. The Plan says you have not failed, had an inadequate response, or intolerance to Euflexxa, Supartz, Durolane, or Gelsyn-3.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 denyingthe request to pre-approve Orthovisc. Our physician reviewer found that you have a history of osteoarthritis of the knee. You havefailed medical therapy with NSAIDs and cortisone injections. The Plan requires a trial of Euflexxa, Supartz, Durolane, or Gelsyn-3 before they will approve the requested drug. In this case, you havenot tried and failed the required drugs.There is no documentation provided indicating that the Plan's required drugswould likely be less effective, or likely have adverse effects.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met.Therefore, we decided that the Plan does not have to pre-approveOrthovisc
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Set-up portable x-ray equipment coded Q0092 and the transportation of portable x-ray equipment coded R0070 provided on May 18, 2020.You asked the Plan to pay forthe Set-up portable x-ray equipment and the transportation of portable x-ray equipment. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not separately payable.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes Q0092 and R0070 are not supported in the medical record. Specifically, when theenrollee is in a Part A Skilled Nursing Facility stay, the transportation and set up costs are subject to consolidated billing and are not separately billable to Medicare Part B. Based on this information, we decided that Medicare rules for coverage of the Set-up portable x-ray equipment and the transportation of portable x-ray equipment have not been met.Therefore, we decided that the Plan does not have to pay forthe Set-up portable x-ray equipment coded Q0092 and the transportation of portable x-ray equipment coded R0070 provided on May 18, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ECG provided by a participating provider on May 14, 2020.You asked the Plan to waive the copayment for an ECG. You say that you were told by your primary to appeal this amount. 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 $30 copayment for outpatient diagnostic tests/non-radiological diagnostic services. You have been asked to pay $18.75 which is less than your copayment amount of $30 for an ECG. An ECG falls within the outpatient diagnostic tests/non-radiological diagnostic 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 an ECG provided by a participating provider on May 14, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran echocardiography (99308) provided on August 20, 2020.You asked the Plan to pay forthe echocardiography. You say that the services were medically necessary.The Plan denied your request. The Plan says there were 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 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay foran echocardiography (99308) provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, panoramic x-ray, prophylaxis, and mandibular partial denture provided on July 15, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, panoramic x-ray, prophylaxis, and mandibular partial denture. You say that you should be reimbursed for the amount of $971.00. You also say that the Plan should have paid up to $2,000.00. The Plan denied your request. The Plan says these services were performed by a non-participating provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.
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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, panoramic x-ray, prophylaxis, and mandibular partial denture provided on July 15, 2020 by an OON provider.
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 an IRF is the appropriate level of care and going without it will impact the enrollee's health negatively. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.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 that the complexity ofthe 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 a stroke. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. 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 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 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foremergency care provided on July 31, 2020.You asked the Plan to waive the copayment foremergency care. You say that you did not receive the X-ray and left the ER so should not be liable for the copayment.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 $50 copayment for emergency care. The medical records show that you received emergency care on July 31, 2020. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for emergency care. Emergency care falls within the emergency care benefit category. This means that you have been asked to pay the correct amountbased 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 foremergency care provided on July 31, 2020.