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

We decided that the Plan does not have to pay for genetic testing (81219, 81270) provided.

You asked the Plan to pay for the genetic testing. You say that the services were medically necessary.The Plan denied your request. The Plan says the documentation does not support the CPT codes billed.

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 code 81219, 81270 is not supported in the medical record. Specifically, per Local Coverage Article: Billing and Coding: MolDX Targeted and Comprehensive Genomic Profile Sequencing Testing in Solid Tumor Cancers (A55624), these services cannot be unbundled and must be reported using CPT code 81479. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met.Therefore, we decided that the Plan does not have to pay for genetic testing (81219, 81270) provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 4, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 physician's services provided on May 4, 2020.
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 enrollee's condition has stabilized, 
and they are ready for discharge from the acute care hospital. You also say that the enrollee needs to be 
transferred to a LTACH to regain their maximum prior level of functioning. The Plan denied your request. The 
Plan says your request 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 enrollee still 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 she is currently receiving care. Our reviewer found that 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 Plan. Our physician reviewer also found that 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 LTACH services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says the enrollee does not require skilled care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that the enrollee had stable vital signs and was generally asymptomatic.Hedoes not have complex wound care or other ongoing SNF level skilled nursing needs.He does notdid not need IV antibiotics, specialized breathing treatments, or other SN need. Vital sign monitoring does not require a SNF admission.The enrollee's functional level does not require a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require skilled nursing or skilled therapy services on adaily basis. As a practical matter, hedoes not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88108) provided February 12, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim is a duplicate.
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 code 88108 is not supported in the medical record. Specifically, the record shows that this CPT code was already paid for this date of service under claim # 820201210119639. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (88108) provided February 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete series intraoral x-ray provided on September 2, 2020. You asked the Plan to pay forthe complete series intraoral x-ray. You say that you were informed the dentist was in-network, but three items were not covered.The Plan denied your request. The Plan says complete series x-rays are only covered once every three 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, the Plan also has a maximum benefit of one complete series x-ray every three years. The Plan paid for a complete series x-ray provided on February 5, 2020, which exhausted your benefit.Therefore, we decided that the Plan does not have to pay forthe complete series intraoral x-ray provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foradministration of the Tdap vaccine received on October 6, 2020.You asked the Plan to pay forthe vaccine. You say that this should be covered as a preventive vaccine.The Plan denied your request. The Plan says this is not a covered benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the 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 vaccine.Therefore, we decided that the Plan does not have to pay foradministration of the Tdap vaccine received on October 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee currently meets IRF admission criteria. The Plan denied your request. The Plan says the enrollee can safely receive the services they need in other settings, and the request 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 above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 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. Our physician reviewer also found that 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (HCPCS S9328) services provided to
the enrollee from March 11, 2020 to May 20, 2020.
You asked the Plan to pay for the therapy. You say that this should be paid for. The Plan denied your request.
The Plan says this code is not recognized.
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 S9328 is "Home infusion therapy, implanted pump pain
management infusion; administrative services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and nursing visits coded separately), per diem."
We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the therapy have
not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (HCPCS
S9328) services provided to the enrollee from March 11, 2020 to May 20, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 15, 2020, by an OON provider.
You asked the Plan to pay for a drug test. You say that these services were medically necessary. The Plan denied your request. The Plan says rules for payment have not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on June 15, 2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life 2000 portable ventilator.
You asked the Plan to pre-approve the requested item. You say that the enrollee will be able to carry out
activities of daily living. The Plan denied your request. The Plan says the enrollee does not require ventilation
continuously.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 requested item. Our physician
reviewer found that this system consists of a portable delivery system with positive pressure oxygen, to be used
during activity. It is not a true ventilator. There is insufficient evidence of efficacy in the treatment of COPD.
Furthermore, there are no ABG data, and BiPAP has not been tried. Therefore, the Life2000 ventilation system
is considered 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 requested item have not been met. Therefore, we decided that the Plan does
not have to pre-approve a Life 2000 portable ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. 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 you do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. Our reviewer found that there are no services available at the LTACH that you require that are not available at the health care setting being offered by the Plan. Our physician reviewer also found that the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition you have 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-approveLTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is highly motivated to return to her prior level of independence. The Plan denied your request. The Plan says the enrollee does not have complex rehab needs requiring the oversight of a physiatrist.
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 physician reviewer found that the enrollee was admitted to the acute hospital for right sided weakness and diagnosed with a stroke. Her medical conditions are stable. The complexity of her nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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: Imaging
Decision: Favorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on March 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 were not met. Maximus administratively overturned due to a lack of clear claim information. The Plan requested a reopen and provided additional claim information. The Plan stated that this claim denied  because payment for this service was previously paid on another claim from a provider of the same specialty group. The Plan says that the NPI website shows that both doctors are diagnostic radiology specialists. The Plan included the claim images for each provider. The claims show both providers belong to the same practice. 

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 CPT code. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty, in the same group, or in the same practice, only one service may be reported unless the evaluation and management services are for unrelated problems. Based on the  records provided, this claim cannot be paid as billed due to the physician group relationship between the two providers. There is no indication this was a separate and distinct service from the claim previously billed. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on March 13, 2020 and billed under the above-mentioned claim.
Appeal type: Imaging
Decision: Favorable


 
We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the upper extremity 
(73221). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
MRI is medically necessary. Our physician reviewer found given the nature of the diagnosis (capsulitis) and 
given lack of improvement in symptoms a better characterization and ability to diagnose the cause of the pain 
is required. The MRI is appropriate. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
Magnetic Resonance Imaging (MRI) of the upper extremity (73221).  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one (1) Dexom G6 Receiver, 1 Dexcom G6 Transmitter,
and 1 Dexcom G6 Sensor.
You asked the Plan to pre-approve the supplies. You say that the supplies are necessary. The Plan denied your
request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
You have not been prescribed insulin as you are currently refusing medical management. The Plan states you
have been ordered to test your blood sugars twice per day. The requirements are: (1) You've been checking
your blood sugar at least four times a day. (2) You take insulin at least three times a day or use a continuous
insulin pump. And (3) you require frequent insulin adjustments based on your blood sugar results. Based on
this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we
decided that the Plan does not have to pre-approve one (1) Dexom G6 Receiver, 1 Dexcom G6 Transmitter,
and 1 Dexcom G6 Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forphysician services provided September 18, 2020.You asked the Plan to waive the copayment forthe physician services. You say that the copayment should be waivedThe Plan denied your request. The Plan says the correct copayment was 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 $5 copayment for office visits. You have been asked to pay a $5 copayment for the physician services. The physician services fall within the 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 forphysician services provided September 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe fillings provided on August 31, 2020.You asked the Plan to pay forthe dental services. You say that these were the first fillings that you received in 2020.The Plan denied your request. The Plan says 2 fillings per calendar year are covered. The Plan also says that the frequency limit 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 2 fillings per calendar year has been exceeded. The record shows that the Plan processed and paid for 2 fillings that you received on September 2, 2020. Although the date of service is later than the date of service in this case, that claim was processed first.Therefore, we decided that the Plan does not have to pay forthe fillings provided on August 31, 2020