Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on January 11, 2021.

You asked the Plan to pay for a limited oral evaluation. You say that the service was necessary. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one per 12-month period.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on August 26, 2020.

Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement provided on March 31, 2021 by an out of network provider.
You asked the Plan to pay for debridement (11042, 11043, 11044). You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request 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 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 debridement provided on March 31, 2021 by an out of
network provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammography (77066) provided on February 24, 2021.
You asked the Plan to pay for the mammography. The Plan denied your request. The Plan says the services were billed on a duplicate claim.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one previously processed and paid by the Plan. Duplicate claims are not payable. Based on this information, we decided that Medicare rules for coverage of the mammography have not been met. Therefore, we decided that the Plan does not have to pay for the mammography (77066) provided on February 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyzulta Sol 0.024% for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is denied as a benefit exclusion.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vyzulta Sol 0.024% for the enrollee.
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 inpatient rehabilitation is necessary for this enrollee. The Plan denied your request. The Plan says the records show the enrollee would benefit from continued physical and occupational therapy. The records show that the enrollee's rehabilitation needs do not require an intensive team for them to reach their functional goals. The necessary services can be provided in another setting, such as a skilled nursing facility or home with home health and home physical therapy.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray coded 71045 provided on May 15, 2021.

You asked the Plan to pay for the chest x-ray. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045 for the chest x-ray has a bundled relationship with code 32555 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray coded 71045 provided on May 15, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve weight loss surgery.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary in order to qualify for shoulder surgery. The Plan denied your request. The Plan says that all of the requirements have not been met.
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically necessary and the applicable criteria is 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 pre-approve the surgery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you have a BMI that 52.35 kg/m2, meeting the applicable criteria requirements. You have several weight-related comorbid conditions, including asthma and degenerative joint disease. The shoulder and knees will need operative repair which cannot be offered secondary to your body habitus and elevated BMI. You have failed dietary efforts, including three months of supervised weight loss efforts. 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 been met. Therefore, we decided that the Plan has to pre-approve weight loss surgery.
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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says step therapy criteria have not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found the Plan requires a trial of Alendronate and Zoledronic Acid before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vascular surgery consultation to be performed by a
tertiary care provided.
You asked the Plan to pre-approve the consultation. You say that you have had abdominal pain for four (4)
months now and your doctors have redirected you back to this provider for consultation since he performed
your previous surgery. The Plan denied your request. The Plan says the notes do not show that you need a more
advanced test or treatment, they do not show there is continuity of care, the notes do not show that a redirection
could cause a delay in care and you do not need a higher level of care.
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 provider at issue in this case is not a network provider with the Plan. 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 consultation. Our physician reviewer found you were sent to the surgeon
that had performed your last surgery (cholecystectomy) prior to your chronic abdominal pain started.
Although reasonable to consider consultation with the prior surgeon in this case, the workup and possible treatment options would be the same if you saw an in-network or out-of-network surgeon, and so for that
reason, this request for referral to your requested provider will be considered not medically necessary based on
the provided 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 consultation have not been met. 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 the consultation. Therefore, we decided that the Plan
does not have to pre-approve the vascular surgery consultation to be performed by a tertiary care provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided October 22, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says there was no documentation provided to support the expectation that the enrollee would require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the hospital with left arm edema for one month. Her history was significant for a poorly functioning kidney transplant from 2019 and status post dilation of left cephalic arch stenosis a few weeks prior to presentation. She was admitted and underwent AVF excision without complication. The records show that she was hemodynamically stable with normal vitals, no pain, and only the edema. The procedure and medical history did not predict a need for a hospitalization that would have likely crossed 2 midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided October 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for health screening genetic testing provided on February 12, 2021.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this testing is not covered by Medicare for the diagnosis listed and was performed for screening purposes.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal, genetic testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for health screening genetic testing provided on February 12, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT of the head or brain, total metabolic panel, glucose, troponin, CBC, prothrombin time, PTT, ECG tracing, and ED visit provided on December 3, 2020.
You asked the Plan to pay for the CT of the head or brain, total metabolic panel, glucose, troponin, CBC, prothrombin time, PTT, ECG tracing, and ED visit. You say that this claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. The Plan denied your request. The Plan says
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the CT of the head or brain, total metabolic panel, glucose, troponin, CBC, prothrombin time, PTT, ECG tracing, and ED visit provided on December 3, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for behavioral health services provided on May 26, 2020, to June 17, 2020 by an out of network (OON) provider.

You asked the Plan to pay for behavioral health services. You say that you were unaware that the member had a very specific plan. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services. The Plan says that there are in-network providers available for these services.

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 behavioral health services provided on May 26, 2020, to June 17, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on October 27, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyOwn skin for the enrollee.

You asked the Plan to pre-approve treatment with MyOwn skin for the enrollee. You say that this treatment is
medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria
were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did
not apply the correct criteria.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for MyOwn skin.
The Maximus Physician Reviewer determined that the services were medically necessary because the wound of
facial skin is opened and needs a graft to heal. The Plan argues that there are few published studies addressing
the use of MyOwn Skin. The Plan states it is not possible to conclude whether MyOwn skin has a beneficial
effect on health outcomes. The Plan notes that the medical records do not discuss prior treatment options or that
the wound is chronic.

Our Medical Director has concluded that the Plan is correct in this case. MyOwn skin is an autologous skin
product which is manufactured from a patient's partial-thickness skin graft. It is composed of viable skin cells
and an organized extracellular matrix. The product is classified as a Skin Graft and is processed under FDA
Regulation 361, which allows for a minimally manipulated autologous product. There is insufficient evidence
that MyOwn Skin improves patient outcomes in this setting. Medical necessity has not been established.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this treatment have not been met. Therefore, we decided that the Plan does not
have to pre-approve MyOwn skin.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided from July 7, 2020, to August 6, 2020.
You asked the Plan to pay for the psychotherapy. You say that you have been seeing this provider for over 10 years and there has been no issue with reimbursement. The Plan denied your request. The Plan says the services billed were not urgent or emergent and are not covered by the Plan.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from July 7, 2020, to August 6, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a comprehensive oral evaluation (D0150), a teeth cleaning (D1110), and an intraoral complete series of radiographic images (D0210) provided on February 25, 2021.
You asked the Plan to pay an additional amount for a comprehensive oral evaluation, a teeth cleaning, and an intraoral complete series of radiographic images. You say that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says the provider was paid at the Medicare allowed rate therefore no additional payment can be made.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, a teeth cleaning, and an intraoral complete series of radiographic images have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Therefore, we decided that the Plan does not have to pay an additional amount for a comprehensive oral evaluation (D0150), a teeth cleaning (D1110), and an intraoral complete series of radiographic images (D0210) provided on February 25, 2021.