Persius/hicric huggingface dataset:
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 an IRF is medically necessary for this enrollee. The Plan denied your request. The Plan says an IRF is not appropriate in this case, and the necessary services can be provided in another setting.
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 that 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 does require physical and occupational therapy, but there is no documented 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. Medically necessary services can be provided in a different 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve respiratory assist device, bi-level pressure capability,
with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device
with continuous positive airway pressure device) (CPT code E0471RR).

You asked the Plan to pre-approve the DME. You say that you do not sleep longer than six (6) hours a night
but recently you had personal issues going on. You state you could not take the machine with you and are
unable to afford the machine without the insurances help. The Plan denied your request. The Plan says you
have used the CPAP device seven (7) percent of the time within the ninety initial days of therapy; therefore, we
cannot authorize this request at this time.

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 DME. Our physician reviewer
found the E0471RR PAP device is considered not medically necessary, because you have been unable to use
the device sufficiently for it to be effective. Two (2) separate compliance reports covering almost four (4)
months indicate you had minimal use of the device, and the minimum Medicare usage requirement, of at least 4
hours/day for at least 70% of days, was not met. The denial is upheld.

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 DME have not been met. Therefore, we decided that the Plan does not have
to pre-approve respiratory assist device, bi-level pressure capability, with back-up rate feature, used with
noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway
pressure device) (CPT code E0471RR).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture (D5213).
You asked the Plan to pre-approve the upper partial denture (D5213). You say that the initial partial required excessive retrofitting due to the extreme amount of bone loss from a failing implant. You say that a total replacement is the practical option for comfort and serviceability. The Plan denied your request. The Plan says procedure code D5213 is only covered once 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, an upper partial denture (D5213) is only covered once every five plan years. The Plan paid for an upper partial denture provided on April 19, 2019, which exhausted the benefit. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4Kscore testing provided on January 8, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that 4Kscore testing is covered when the criteria in the applicable LCD are met. 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 the testing. Our reviewer says that the requested 4Kscore testing is not medically reasonable and necessary in this case. Our physician reviewer found that the 4kScore is not indicated when life expectancy is less than 10 years. Therefore, the requested 4Kscore test is not medically reasonable and necessary according to the coverage criteria established in the above LCD. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 4Kscore testing provided on January 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Part B drug and the intravitreal injection provided on February 15, 2021.
You asked the Plan to waive the cost share for the Part B drug and an intravitreal injection. You say that you only received one eye injection in the left eye. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 30% of the total cost for out-of-network Medicare-covered drugs and administration and a $200 copayment for each out-of-network Medicare-covered outpatient hospital service. You have been asked to pay $290.57 which is 30% of the allowed amount for the Part B drug. The allowed amount is $986.56. ($986.56 x 30% = $290.57). You have also been asked to pay a $200 copayment for the intravitreal injection. The Part B drug falls within the "Medicare Part B prescription drugs" benefit category. The intravitreal injection falls within the "Outpatient hospital services" benefit category. The record shows the intravitreal injection is considered a separate outpatient procedure and that you only had the injection in the left eye.
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 cost share for the Part B drug and the intravitreal injection provided on February 15, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99285) provided January 28, 2021.
You asked the Plan to pay for the emergency visit. You say that the records were submitted for review of the services rendered. The Plan denied your request. The Plan says the records do not support the billed service. The claim was reprocessed and paid based on the level supported by the records.
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect the services provided.
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the evaluation and management of a patient which requires three components (taking into account the urgency of the clinical condition or the patient's mental status): 1. a comprehensive history; 2. a comprehensive examination; and 3. medical decision making of high complexity. In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate significant threat to life or physiologic function. 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 the emergency visit Our reviewer says that the use of 99285 is not supported by the medical records. Our reviewer found the emergency room evaluation and management documentation does not support level 99285. Documentation submitted includes a Comprehensive History and Exam, with Moderate level of Medical Decision Making. Per CPT guidelines, documentation must meet or exceed 3 of 3 key components to support the level of evaluation and management. There is a more appropriate code for documentation submitted, CPT 99284. 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 emergency visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99285) provided January 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to be transferred to LTACH instead of lower level of care as he will require another 4-6 weeks in acute care for transitioning from acute illness. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided indicating medical necessity for the requested LTACH services. The enrollee 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, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, each tendon (CPT code(s): 26145-59-F7, 26145-51-F7 and 26145-59-51-F5) provided to the enrollee on February 4, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
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 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 the services. Our physician reviewer found the services, synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, each tendon (CPT 26145-59-F7, 26145-51-F7, and 26145-59-F5), are not supported by the medical records. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, each tendon (CPT code(s): 26145-59-F7, 26145-51-F7 and 26145-59-51-F5) provided to the enrollee on February 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that 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 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 the patient appears to be improving gradually but still requires additional short-term acute care services for additional weaning and more stability with percutaneous endoscopic gastrostomy (PEG) placement which can be safely be completed at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient 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 the patient is more stable and 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-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis services provided to the enrollee on January 1, 2021.
You asked the Plan to pay for the services. You say that the claim was billed appropriately with the correct modifiers required by law. The Plan denied your request. The Plan says the required modifier for end stage renal disease services is missing or invalid.
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 the denied codes is: CPT 90999: unlisted dialysis procedure, inpatient or outpatient HCPCS J0606: Injection, etelcalcetide, 0.1 mg HCPCS J1644:
Injection, heparin sodium, per 1000 units We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation submitted did not include dialysis notes to confirm the services were performed and support the codes and modifiers reported. CMS guidelines do require appropriate G-modifier for CPT 90999, however, since no documentation of services performed were submitted, confirmation cannot be made for the codes submitted. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for dialysis services provided to the enrollee on January 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve these OON items. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested items can be provided by a network 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 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 power wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266), bone grafts (D6104) and extensive treatment planning (D9450).
You asked the Plan to pre-approve guided tissue regeneration (D4266), bone grafts (D6104) and extensive treatment planning (D9450). The Plan denied your request. The Plan says the services are not covered benefits.
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 pre-approve guided tissue regeneration (D4266), bone grafts (D6104) and extensive treatment planning (D9450).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that 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 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 you appear to be improving gradually but still requires additional short-term acute care services for additional weaning from oxygen support which can be safely be completed at the current facility. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require 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 as there would be no advantage to transfer. 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-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block.
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 medically necessary.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found you have knee pain after a total knee
replacement. The requested genicular nerve block is considered experimental and investigational in nature and
not medically necessary for the treatment of chronic knee pain. The services are therefore not reasonable or
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-approve a genicular nerve block.
Local Coverage Determination (LCD) L36850 referenced by the Plan is not valid for the services at issue and
was not used in the Maximus determination.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for an inpatient admission and carotid artery stenting.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the services are available in-network.
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 an out-of-network referral for an inpatient admission and carotid artery stenting.