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

We decided that the Plan does not have to pay for an emergency room visit (99285) provided February 6, 2020.
You asked the Plan to pay for the emergency room visit. You say that the services were medically necessary. The Plan denied your request. The Plan says payment for this service was bundled with another code.
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 99285 has a Column I / Column II relationship with code 99291 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 an emergency room visit (99285) provided February 6, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve OncoTypeDX for Breast Cancer testing.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 services are medically necessary. Our physician reviewer found the enrollee has a diagnosis of poorly differentiated invasive ductal carcinoma of the left breast, ER+, PR+, HER2-, clinical stage cT1b. It is noted that she is a candidate for genomic testing if she is lymph node negative. Surgery has not been performed due to restrictions established by the state government in response to the Covid-19 pandemic. While lymph nodes have not been tested, the enrollee's nodes are clinically negative, based on her physical exam and imaging. There is a lack of information regarding the enrollee's lymph nodes, as a result of the Covid-19 pandemic. Given this exceptional situation, OncoTypeDX for Breast Cancer testing can be considered the standard of care for the enrollee's breast carcinoma. The testing is reasonable and 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 been met. Therefore, we decided that the Plan has to pre-approve OncoTypeDX for Breast Cancer testing.
The Local Coverage Article (LCA) referenced by the Plan provides billing information only and not coverage criteria and was not used in the MAXIMUS determination.
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. The Plan denied your request. The Plan says the enrollee does not have complex medical conditions which require physician supervision, or a multidisciplinary team for care.
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 you underwent revision of hardware, placement of new iliac screws, and a bilateral sacroiliac fusion. You are at supervision for bed mobility, contact guard assist for transfers and ambulating with a rolling walker. In occupational therapy, you were at supervision for grooming, total assist for lower body dressing, moderate assist for upper body dressing, and contact guard assist for transfers and bed mobility. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You have had no significant post-operative complications. You may benefit from multiple therapies, such as physical and occupational therapy, but the documentation does not support that this therapy must be on an intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided January 14, 2020 to January 15, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the self-administered drugs provided are not a covered benefit under your contractual policy.
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 provided are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs (A9270) provided January 14, 2020 to January 15, 2020.
Benefits for the medications provided 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 the drug testing rendered on February 25, 2019.
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 G0482 is 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 G0482 is definitive drug testing, 15-21 drug classes. We find that CPT code G0482 is not supported in the medical record. Specifically, there is no documentation of testing of 15-21 drug classes. 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 drug testing rendered on February 25, 2019.
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 needs to work on strengthening her extremities, and improve fine motor strength. The Plan denied your request. The Plan says the enrollee does not have acute or new medical conditions that require physician supervision, or a multidisciplinary team for care.
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 has weak lower extremities. She is not able to transfer alone, and needs max assist for dressing, bathing, and grooming. 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 medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies, such as physical and occupational therapy, but the documentation does not support that she requires this therapy on an intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on March 4, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on March 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 enrollee required maximum assistance/dependent for transfers, lower body dressing, bathing, and sit to supine. The enrollee required moderate assistance with supine to sit and upper body dressing. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the enrollee requires an intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiographic images provided on November 25, 2019.
You asked the Plan to pay for the radiographic images. You say that you were not advised what x-rays are covered. The Plan denied your request. The Plan says that this is not a covered service.
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 radiographic images provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ultrasound and the bladder capacity measurement provided on February 3, 2020.
You asked the Plan to waive the copayments for the ultrasound and the bladder capacity measurement. You say that you were never told that there would be an extra charge for the ultrasound. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $155 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility and a $30 copayment for Medicare-covered non-radiological diagnostic services. For this date of service, you have been asked to pay the allowed amounts of the claim because these amounts are less than the $155 copayment for the ultrasound and the $30 copayment for the bladder capacity measurement.
You have been asked to pay a $149.10 copayment for the ultrasound and a $9.90 copayment for the bladder capacity measurement. The ultrasound and the bladder capacity measurement fall within "Outpatient diagnostic tests and therapeutic services and 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 copayments for the ultrasound and the bladder capacity measurement provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visits provided on
November 14, 2019 and December 2, 2019.
You asked the Plan to waive the copayment for the urgent care visits. You say that you didn't know you had a
copayment for urgent care visits. The Plan denied your request. The Plan says the copayments applied
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 $35
copayment per visit for Medicare-covered urgently needed services.
You have been asked to pay a $35 copayment for each urgent care visit. The urgent care visits fall within the
"Urgently needed services" benefit category. This means that you have been asked to pay the correct amount
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the urgent
care visits provided on November 14, 2019 and December 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a drug regimen Carboplatin (J9045), Fosaprepitant
(J1453), Ondansetron HCL (J2405), Atezolizumab (J9022), Etoposide (J9181), and Lorazepam (J2060).
You asked the Plan to pre-approve a drug regimen Carboplatin, Fosaprepitant, Ondansetron HCL,
Atezolizumab, Etoposide, and Lorazepam. You say that this regimen is necessary because the enrollee has a
rare and aggressive tumor. The Plan denied your request. The Plan says this drug regimen is not supported by
the records for the enrollee's specific cancer.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a drug regimen Carboplatin,
Fosaprepitant, Ondansetron HCL, Atezolizumab, Etoposide, and Lorazepam. Our reviewer says that this drug
regimen is not supported in this case. Our physician reviewer found the enrollee has a diagnosis of for the
treatment of high grade metastatic large cell neuroendocrine tumor of the small intestine. Review of the
compendia, including NCCN, does not support the use of this regimen for the enrollee's diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a drug regimen Carboplatin, Fosaprepitant, Ondansetron HCL, Atezolizumab,
Etoposide, and Lorazepam have not been met. Therefore, we decided that the Plan does not have to preapprove
a drug regimen Carboplatin (J9045), Fosaprepitant (J1453), Ondansetron HCL (J2405), Atezolizumab
(J9022), Etoposide (J9181), and Lorazepam (J2060).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 10, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound compression system application
provided from December 19, 2019 through March 9, 2020.
You asked the Plan to waive the copayment for the wound compression system application. You say that there
should only be a $15 copayment for physical therapy. The Plan denied your request. The Plan says the
copayments applied 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 $325
copayment for an outpatient hospital facility visit in 2019 and a $350 copayment for an outpatient hospital
facility visit in 2020.
You have been asked to pay a total of $120 for the wound compression system application.
The wound compression system application falls within the "Outpatient surgery, including services provided at
hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the wound compression system application provided from December 19, 2019
through March 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for skilled nursing services provided October
1 to October 3, 2019.
You asked the Plan to waive the coinsurance for the skilled nursing services. You say that the coinsurance
should be waived because you did not request the services. The Plan denied your request. The Plan says the
correct cost sharing 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 10%
coinsurance for days 1-100 for Skilled Nursing Facility Care.
You have been asked to pay a 10% coinsurance for 3 days of skilled nursing services. The skilled nursing
services fall within the Skilled Nursing Facility Care benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
coinsurance for skilled nursing services provided October 1 to October 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 9, 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 the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure
code 81479.
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on March 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 9, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered on July 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (EKG) reading provided February 13,
2020.
You asked the Plan to pay for the EKG reading. You say that the services were medically necessary and
correctly billed. The Plan denied your request. The Plan says the records do not support separate payment for
an EKG interpretation.
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 93010 is not supported in the medical record. Specifically, the records provided are
limited to a single EKG strip from the Emergency Room. There is no interpretive report prepared by a
physician. Payment for a simple review of an EKG strip is bundled in the payment for the emergency room
services. Based on this information, we decided that Medicare rules for coverage of the EKG reading have not
been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (EKG) reading
provided February 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 17, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered on February 17, 2020.