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

We decided that the Plan does not have to pre-approve Glassia infusions.
You asked the Plan to pre-approve Glassia. The Plan denied your request. The Plan says the documentation does not support the use of the medication for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Glassia. Our physician reviewer found that the enrollee has chronic obstructive pulmonary disease with an AAT genotype of MS. With one normal allele (M), the expectation is that the enrollee is able to make enough alpha-1 protease inhibitor to be protective, and this is confirmed by the normal AAT level of 146. This enrollee does not have A1AT deficiency, and therefore replacement therapy would not be beneficial. Therefore, Glassia infusions are 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 Glassia have not been met. Therefore, we decided that the Plan does not have to pre-approve Glassia infusions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4342) provided November 18, 2020.

You asked the Plan to pay for the periodontal scaling and root planing. You say that you were unaware that you would be charged for the services. The Plan denied your request. The Plan says this service is not a covered under your benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4342) provided November 18, 2020.

Your complaint about potential misinformation given to you by the provider about coverage prior to the services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
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 services can be safely received in other settings, for example, a skilled nursing facility, home with home health services, or home with outpatient 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. admitted for respiratory failure and pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the trigger point injection services provided on October 14, 2020.

You asked the Plan to pay for the trigger point injection services. 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 supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 20552 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the trigger point injection services have not been met. Therefore, we decided that the Plan does not have to pay for the trigger point injection services provided on October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home injectable therapy (S9542) provided on September 11, 2020, through October 2, 2020.
You asked the Plan to pay for the home injectable therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code S9542 has a status indicator of I and 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 S9542 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9542 has a status indicator of I. This means that this CPT code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home injectable therapy have not been met. Therefore, we decided that the Plan does not have to pay for home injectable therapy (S9542) provided on September 11, 2020, through October 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor (K0554) and supplies (K0553) provided from July 27, 2020, to September 28, 2020.

You asked the Plan to pay for a continuous glucose monitor and supplies. You say that the provided items meet Medicare criteria. The Plan denied your request. The Plan says these items were provided following an unsolicited phone call.

The Plan must follow Medicare rules. Medicare rules say that that a supplier of a covered item of durable medical equipment (DME) may not contact an individual by telephone regarding the furnishing of a covered item to the individual unless the individual has given written permission to the supplier to make contact by telephone regarding the furnishing of a covered item, or the supplier has furnished a covered item to the individual and the supplier is contacting the individual only regarding the furnishing of such covered item, or another covered item to this same individual within 15 months. 

We looked at the file and Medicare rules. The Plan and the enrollee have attested that these items were provided following an unsolicited phone call. The submitted documentation does not sufficiently show that the enrollee provided written permission to be contacted regarding the furnishing of the items at issue. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (K0554) and supplies (K0553) provided from July 27, 2020, to September 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing services provided by a participating provider on March 1, 2020, to May 29, 2020.
You asked the Plan to waive the copayment for skilled nursing services. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayment has been 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment per day for days 1-20. There is a $178 copayment per day for days 21-100 for skilled nursing facility (SNF) care/in-network. The enrollee has been asked to pay a $0 copayment per day for days 1-20. There is a $178 copayment per day for days 21-61 for skilled nursing services. You are being asked to pay a total of $6,340 due to reaching your out-of-pocket maximum. Skilled nursing services falls within the skilled nursing facility (SNF) care/in-network benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing services provided by a participating provider on March 1, 2020, to May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (99202) provided to you on December 7, 2020.
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services (99202) provided to you on December 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit (99336) and chronic care management
(99490) provided on January 13, 2021, by an OON provider.
You asked the Plan to pay for the rest home visit and chronic care management. You say that you would like
reconsideration because it is the responsibility of the facility to get authorization. The Plan denied your request.
The Plan says these out-of-network services were not urgent, emergent, or approved in advance.
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 the rest home visit (99336) and chronic care
management (99490) provided on January 13, 2021, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vancomycin.
You asked the Plan to pre-approve Vancomycin. You say that the enrollee's infection has recurred. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.
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 Vancomycin.
Benefits for Vancomycin may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Genetic Testing services (CPT code (s): 81406, 81479, and 81408) provided to the enrollee on October 13, 2020.

You asked the Plan to pay for the genetic testing. You say that the services should be covered by the Plan as it was medically necessary. The Plan denied your request. The Plan says the diagnosis does not support approval for genetic testing and unlisted molecular pathology.

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, the 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 Genetic Testing services (CPT code (s): 81406, 81479, and 81408) provided to the enrollee on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on November 4, 2020, and December 4, 2020.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you cannot afford 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 20% coinsurance for DME and related supplies. You received DME and related supplies on November 4, 2020. The total allowed amount is $2,925.60 and 20% of that is $585.12. You received DME and related supplies on December 4, 2020. The total allowed amount is $2,925.60 and 20% of that is $585.12. The total amount you owe is: $1,170.24. You have been asked to pay the total coinsurance amount of $1,170.24 for DME and related supplies. DME and related supplies fall within the DME and related supplies 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 coinsurance for DME and related supplies provided on November 4, 2020, and December 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services rendered on December 1, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 64999 should not be billed by an anesthesia practitioner.

The Plan must follow Medicare rules. The rules say that CPT codes describing anesthesia services (00100-01999) or services that are bundled into anesthesia should not be reported in addition to the surgical or medical procedure requiring the anesthesia services if performed by the same physician. 

We looked at the file and Medicare rules. The file shows that procedure code 64999 (unlisted procedure, nervous system) was billed by an anesthesia practitioner and is an inappropriate billing of this code. 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 pay for the outpatient services rendered on December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on October 14, 2020.
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 to the enrollee by an out-of-network provider on October 14, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care provided from November 17, 2020, through November 19, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay was not necessary.

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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the documentation supports that, at the time of inpatient admission, it was reasonable for the admitting physician to expect that your necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two 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 been met. Therefore, we decided that the Plan has to pay for inpatient hospital care provided from November 17, 2020, through November 19, 2020.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments charged for an office visit provided by a specialist on April 23, 2020 and May 7, 2020.
You asked the Plan to waive these copayments. You say that you cannot pay this each time you go to the doctor. The Plan denied your request. The Plan says this copayment was charged based on the services provided and the claim submitted by your physician. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct contract language.
The Plan is correct in this case. 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 $35 copayment for each specialist visit. 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 copayments charged for an office visit provided on April 23, 2020 and May 7, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the services (15273, 15274) provided on October 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed codes
are 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 15273 is "Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or
equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children." The CPT
Code Manual definition of code 15274 is "Application of skin substitute graft to trunk, arms, legs, total wound
surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof,
or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code
for primary procedure)."
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 reviewers says that the use
of CPT codes 15273 and 15274 is supported by the records provided. Our coding reviewer found that PuraPly
is a skin substitute graft, which is cut to outline the wound area for coverage of the entire wound and fixated in
place by non-adherent dressings.
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 been met. Therefore, we decided that the Plan has to pay for
the services (15273, 15274) provided on October 7, 2020.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on December 15, 2020.

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 to the enrollee by an out-of-network provider on December 15, 2020.