Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy (90834) provided on March 12, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that You have attached the supporting documents. Kindly review and process the claim towards payment. The Plan denied your request. The Plan says Medicare payment for clinical psychologist's services is limited to treatment by practitioners with a Psychology Doctoral degree, Licensed or certified in the State, with patient consent, and consult with the attending or primary care physician. There was no documentation of one or more of the criteria in the patient's medical record. Enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 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 individual psychotherapy (90834) provided on March 12, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on November 2, 2020.

You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. 

Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129, L36362 and L36523 to support their denial. However, LCD L36139, L36129, L36362 and L36523 are not valid for the provider's billing state of New Mexico. Therefore, we are unable to use LCD L36139, L36129, L36362 and L36523 to substantiate our decision. 

While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on November 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra.

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. 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 not medically necessary. Our physician reviewer found the enrollee has severe persistent asthma with acute exacerbations. Fasenra is FDA-approved for severe eosinophilic asthma. The records contain comments implying a prior elevated eosinophil, but there are no direct records or listing of a diagnosis of of eosinophilic asthma to help justify the use of Fasenra. Therefore, without sufficient supportive documentation of this diagnosis, the Fasenra will be considered not medically necessary or safe and effective for the enrollee at this time. 

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 Fasenra.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 12,1 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services 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 for the services provided by an out-of-network provider on January 12,1 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (93971, J1815) provided to the enrollee on November 1, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denial has been applied for correct coding guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT or Healthcare Common Procedure Coding System (HCPCS) code. In this case, the CPT Code Manual definition of the denied codes is: HCPCS J1815: Injection, insulin, per 5 units
CPT 93971: Duplex scan of extremity veins including responses to compression and other maneuvers 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 J1815 is considered self-administered insulin and would not be covered. For CPT 93971, the reported ICD-10 codes for diabetes and hypertension do not support the need for this procedure. The diagnosis for the reason this procedure was performed should be reported. 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 physician services (93971, J1815) provided to the enrollee on November 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on February 22, 2021.
You asked the Plan to pay for the prophylaxis. You say that you were not aware that only one cleaning was allowed to be provided every six months from the previous cleaning. The Plan denied your request. The Plan says this service is not covered under your dental plan 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 Plan covers 2 preventive cleanings and each cleaning must be a minimum of six months apart. You state that you last received a cleaning on December 14, 2020, and your cleanings benefit had been exhausted for the time period. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on February 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Interrogation device evaluation(s), (remote)
up to 30 days (G2066, 93298) provided July 1, 2020 to July 31, 2020.
You asked the Plan to waive the copayment for Interrogation device evaluation. You say that you know this is
a contracting cardiologist, but you don't understand why you are being charged $40 each month when you're
not even seeing anyone. The Plan denied your request. The Plan says the claim was processed with the correct
copayment applied per the Evidence of Coverage.
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 $40
copay for each Medicare covered specialist visit.
You have been asked to pay $40 copay for the interrogation device evaluation. The interrogation device
evaluation falls within the Physician/Practitioner services, including doctor's office visits 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 Interrogation device evaluation(s), (remote) up to 30 days
(G2066, 93298) provided July 1, 2020 to July 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the medical necessity criteria is not met for admission to acute inpatient rehabilitation.
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 you do not require the intensity of services provided at the IRF. Specifically, you are not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services and regular physician evaluation. Your 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the physician services provided during the inpatient stay. We decided that the Plan does not have to waive the copayment for the inpatient hospital care.
You asked the Plan to waive the copayment for the inpatient hospital stay and physician services. You say that you were in the hospital longer than expected due to poor care. The Plan says that the copayments were applied correctly.
We decided that the Plan has to waive the copayment for the physician services provided during the inpatient stay.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that you have a $400 copayment per day, days 1-4 for each Medicare-covered hospital admission/stay. Covered services include but are not limited to such services as physician services, drugs and medications, lab tests, x-rays and other radiology services, etc.
The Plan says you must pay separate copayments for physician service provided during your inpatient hospital stay. Based on the Plan contract, however, these services are included in your inpatient hospital care copayment and you cannot be asked to pay for additional cost-sharing for the physician services. Therefore, we decided that the Plan has to waive the copayments for the physician services provided during your inpatient hospital stay.
We also decided that the Plan does not have to waive the copayment for the inpatient hospital stay.
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 $400 copayment per day, days 1-4 for each Medicare-covered hospital admission/stay.
You have been asked to pay a total of $1,600 ($400 copayment x 4 days = $1,600) for the inpatient hospital stay. This service falls within the Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay from February 2, 2021, to February 8, 2021.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: 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 is not safe to go home at this time and requires intensive rehabilitation care to return to their prior level of function. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met, and the enrollee can receive the necessary care in a less intensive 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a medical eye exam (92014) and an eye refraction (92015) provided on March 31, 2021.

You asked the Plan to pay for a medical eye exam and an eye refraction. You say that you received a routine eye exam. The Plan denied your request. The Plan says your claim processed correctly. The Plan also says that the claim was billed with a medical diagnosis.

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. The Plan contract says that you pay a $45 copayment for each visit to a specialist, for Medicare-covered benefits. The Plan contract also says that an eye refraction is only covered when it is performed as part of a routine service. 

We looked at the file and the Plan's rules. An eye refraction is only covered when it is part of a routine eye exam visit. The records show you had a medical eye exam with a diagnosis for a presence of an intraocular lens. This service was performed for medical vision purposes. The EOC confirms $45 is the required copayment for this office visit with an ophthalmologist. Based on this information, we decided that the Plan's rules for coverage of a medical eye exam and an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for a medical eye exam (92014) and an eye refraction (92015) provided on March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of lateral exostosis (D7471).
You asked the Plan to pre-approve removal of lateral exostosis. You say that the service is necessary and should be covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 removal of lateral exostosis (D7471).
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 need inpatient rehabilitation services. The Plan
denied your request. The Plan says the criteria for an IRF are not met. You can safely receive the services you
need 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 your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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.

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 radiofrequency ablation at the spinal level of L2-L3 (64636).

You asked the Plan to pre-approve radiofrequency ablation at the spinal level of L2-L3. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that an initial thermal radiofrequency ablation (RFA) of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for patients who have had at least two (2) medically reasonable and necessary diagnostic Medial Branch Blocks (MBBs). Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) months or at least 50% consistent improvement in the ability to perform previously painful movements and activities of daily living as compared to baseline measurement using the same scale. 

We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee has had MBBs or previous radiofrequency ablation procedures at this spinal level. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation at the spinal level of L2-L3 have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation at the spinal level of L2-L3 (64636).
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 need inpatient rehabilitation services to help you
retain mobility and walk again. The Plan denied your request. The Plan says the criteria for an IRF are not met.
Your skilled therapy and nursing needs 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 your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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.

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.