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

We decided that the Plan does not have to pay for laboratory services provided on December 16, 2019.You asked the Plan to pay for the laboratory 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 laboratory 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 laboratory services provided on December 16, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 99223) provided on November 26, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says these were not inpatient services.The Plan must follow Medicare rules. Medicare rules say that if the admission order is not properly documented in the medical record prior to discharge, the hospital should not submit a claim for Part A payment. We looked at the file and Medicare rules.The services in question were billed with an inpatient POS code. The records provided do not contain an admission order. Without an admission order, the enrollee is not considered to be under inpatient status.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 forthe services (CPT 99223) provided on November 26, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the cervical spine for the enrollee.You asked the Plan to pre-approve the MRI. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee says that they tried physical therapy without success, but the records do not show when the therapy was.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 requested MRI is not medically reasonable or necessary. Our physician reviewer found there is no documentation of adequate conservative measures, such as physical therapy. There is no neurologic deficit. The MRI is not needed 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 the MRI have not been met.Therefore, we decided that the Plan does not have to pre-approve MRI of the cervical spine for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of an IRF admission.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 of the enrollee's nursing, medical,and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing supervision in an IRF. While the enrollee may benefit from physical and occupational therapy,the documentation does not indicate that the enrollee's functional level requires this on an intensive level in an inpatient rehabilitation facility.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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9328) provided on December 27, 2019 through December 31, 2019.You asked the Plan to pay forthe home infusion therapy. You say that you would like reconsideration because CPT code S9328 is valid per Medicare.The Plan denied your request. The Plan says CPT code S9328 has a status code of I which is not valid for Medicare.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 S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9328) provided on December 27, 2019 through December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the crown for tooth #3. We decided that the Plan does not have to pre-approve the crowns for tooth #'s 18, 31, and 4. You asked the Plan to pre-approve the crowns for tooth #'s 3, 18, 31, and 4. You say that tooth #4 is fractured, is loose and painful, and needs to be fixed. You also say that tooth #3 has a cavity that needs to be fixed.The Plan says that there is a cavity below the bone of tooth #3 which must be treated first. The Plan also says that the x-rays of tooth #'s 18, 31, and 4 do not show that these teeth are badly broken or rotten.We decided that the Plan has to pre-approve the crown for tooth #3. 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 the crown for tooth #3 when the services are medically necessary and reasonable.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 crown for tooth #3. Our reviewer says that the crown for tooth #3 is medically necessary. Our physician reviewer found that tooth #3 meets the criteria for coverage for a replacement crown due to the recurrent caries noted. 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 crown for tooth #3 have been met.Therefore, we decided that the Plan has to pre-approve the crown for tooth #3. We also decided that the Plan does not have to pre-approve the crowns for tooth #'s 18, 31, and 4.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 the crowns for tooth #'s 18, 31, and 4 when the services are medically necessary and reasonable. 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 crowns for tooth #'s 18, 31, and 4. Our reviewer says that crowns for tooth #'s 18,31, and 4 are not medically necessary. Our physician reviewer found that tooth #'s 18, 31, and 4 do not appear to have significant breakdown to meet the criteria for coverage for crowns.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 crowns for tooth #'s 18, 31, and 4 have not been met.Therefore, we decided that the Plan does not have to pre-approve the crowns for tooth #'s 18, 31, and 4.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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on September 9, 2019 through September 16, 2019.You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because CPT code S9328 is valid per Medicare.The Plan denied your request. The Plan says CPT code S9328 has a status code of I which is not valid for Medicare purposes.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 S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I which is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9328) provided on September 9, 2019 through September 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vistaseq multigene testing, including PTEN and BRCA genes.You asked the Plan to pre-approve these services. You say that you have a family history of breast cancer.The Plan denied your request. The Plan says the testing is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that BRCA testing is covered when specific criteria are met and PTEN testing when 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 these services. Our reviewer says that the testing is not medically necessary. Our physician reviewer found the records show that you have a diagnosis of breast cancer but there is no documentation to support that you have a family member with a diagnosis that meets the criteria for coverage. The National Comprehensive Cancer Network (NCCN) guidelines do not support the use of PTEN testing for your condition. The requested testing is 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 Vistaseq multigene testing, including PTEN and BRCA genes.The Plan references LCD L36370 in their determination; however, this LCD is not relevant to the requested services and was not used in the MAXIMUS determination.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for blood glucose services (CPT 82947) provided to the enrollee on March 26, 2019.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 Current Procedural Terminology (CPT) code 82947 (1 Unit) remains not supported.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 82947 is "Glucose; quantitative, blood (except reagent strip)."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 reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found there is no evidence that a blood glucose test was ordered or performed. Therefore, the billing of CPT 82947 is not supported.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 blood glucose services (CPT 82947) provided to the enrollee on March 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance for a therapeutic continuous glucose monitor.You asked the Plan to pay for the therapeutic continuous glucose monitor supply allowance (K0553). You say that the supplies were medically necessary.The Plan denied your request. The Plan says the records are deemed not to be part of the medical record for Medicare payment purposes.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. The office visit notes do not mention a therapeutic continuous glucose monitors or the medical necessity for supplies. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor supply allowance (K0553) have not been met.Therefore, we decided that the Plan does not have to pay for the supply allowance for a therapeutic continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe resin-based composite-four or more surfaces or involving incisal angle provided on December 5, 2019.You asked the Plan to waive the copayment forthe resin-based composite. You say that this should be covered by the Plan because your dentist was fixing a previous filling.The Plan denied your request. The Plan says that you were charged correctly.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 the resin-based composite-four or more surfaces or involving incisal angle. You have been asked to pay a $50 copayment for the resin-based composite. The resin-based composite falls within the resin-based composite-four or more surfaces or involving incisal angle 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 whenyou enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe resin-based composite-four or more surfaces or involving incisal angle provided on December 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvereplacement of a K3 preparatory transtibial prosthesis.You asked the Plan to pre-approvethe prosthesis.. You say that the enrollee needs to have her socket replaced to avoid skin break, ulcerations, and other complications associated with a poor socket fit.The Plandenied your request. The Plan says this request does not meet Medicare criteria as reasonable and necessary. The records show that a new socket is needed. A request for a socket and accessories can be reviewed if submitted.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 prosthesis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found The enrollee requires a replacement of her socket due to a change in limb shape due to remodeling. Her current prosthetic foot can be reused as she has done well with her current prosthetic components including being able to perform the above activities of daily living. The upgraded Osser Proflex XC foot is not medically reasonable or 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 prosthesis. have not been met.Therefore, we decided that the Plan does not have to pre-approvereplacement of a K3 preparatory transtibial prosthesis
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the compounded drugs provided for use with an implanted intrathecal infusion pump on March 11, 2019 and July 3, 2019.
You asked the Plan to pay for the compounded drugs. You say that these were denied for not showing medical necessity. You only provide the drugs which are ordered by the treating physician. The medical necessity of the pump was established when originally implanted. The Plan denied your request. The Plan says there are no records showing that these drugs are helpful for the patient so the plan is not obligated to pay for them.
The Plan must follow Medicare rules. Medicare rules say that compounded drugs for use in an implanted pump are billed with a single line item of code J7999-KD. The codes used in this case are not correct for compounded drugs and there was no modifier KD used which is required for drugs administered through DME. Therefore, we decided that the Plan does not have to pay for the compounded drugs provided for use with an implanted intrathecal infusion pump on March 11, 2019 and July 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you feel intensive inpatient physical therapy would help decrease the enrollee's pain and increase her mobility, which would decrease her chances for a fall. The Plan denied your request. The Plan says the records do not support the need for daily therapy on an inpatient basis.
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 the SNF admission. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve partial removal of nasal sinus, using an endoscope.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of the requested CT and photographic images of the facial nasal region in question.
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 surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the available documentation in the case file is insufficient to demonstrate that the requested services in this case are medically reasonable and necessary for the enrollee in this case. There is no documentation of the medical therapy tried and failed. There is no documented imaging such as a CT scan. There are no photographs submitted for review. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve partial removal of nasal sinus, using an endoscope.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on January 14, 2020.You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit and you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 copayment for primary care provider visits. The medical records show that you received services beyond an annual wellness visit on January 14, 2020. Therefore, you are responsible to pay the $5 copayment. You have been asked to pay a $5 copayment for an office visit. An office visit falls within the physician/practitioner services, includingdoctor'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 an office visit provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a colonoscopy provided on October 2, 2019.You asked the Plan to pay for the colonoscopy. 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 servicesat 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 a colonoscopy provided on October 2, 2019.