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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the member will benefit from short-term rehabilitation. The Plan denied your request. The Plan says that there are no skilled nursing needs identified.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 14 Day Sensor Kit, for the enrollee.
You asked the Plan to pre-approve the sensor. You say that the sensor is appropriate for the enrollee's current diabetes treatment. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the sensor. Our physician reviewer found the enrollee is not taking three (3) shots of insulin daily and we are not told why the enrollee cannot use a glucometer to check their blood glucose instead of a CGM; since the enrollee is not injecting three times daily the enrollee does not meet criteria for CGM coverage. This does not mean that the CGM would not help the enrollee and make it easier for them to control or monitor their blood glucose sugar; it merely means that plan criteria for coverage are not met. 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 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14 Day Sensor Kit, for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested CGM.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, does not use insulin with at least three daily injections, and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an elective total hip arthroplasty to be provided inpatient.
You asked the Plan to pre-approve the elective total hip arthroplasty to be provided inpatient. The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about the enrollee's condition, care could be provided without an inpatient stay after the surgical procedure.
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 pre-approve the elective total hip arthroplasty to be provided inpatient. Our reviewer says that the documentation does not support that the criteria for inpatient coverage are met in this case. Our physician reviewer found that the enrollee is a 78-year-old male with left hip pain. He has a past medical history to include diabetes, high cholesterol, rheumatoid arthritis, history of gout and hypertension. The review indicates that the enrollee is undergoing a planned left total hip arthroplasty. He is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 27130 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. 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 elective total hip arthroplasty to be provided inpatient have not been met. Therefore, we decided that the Plan does not have to pre-approve an elective total hip arthroplasty to be provided inpatient.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of 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 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. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided to the enrollee on April 13, 2020.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient claim information. The Plan requested a reopen and provided additional information. The Plan says that this claim denied because the charges exceed the maximum allowable or contracted legislated fee arrangement for this type of service. Medicare guidelines state with exception to certain services, Indian Health Services are combined and reported under revenue code 0510 (clinic visit) under Type of Bill code 13X (hospital outpatient). The claim image of the appealed claim shows the claim was submitted with a revenue code of 0450 and not the required revenue code of 0510. Medicare billing criteria are not met.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due to an error with the revenue codes billed. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services provided to the enrollee on April 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex surgery.
You asked the Plan to pre-approve Vertiflex surgery. You say that this service is medically necessary. The Plan
denied your request. The Plan says Vertiflex surgery is not medically necessary as it is considered
investigational at this time.
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 Vertiflex surgery. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and
efficacy of the device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vertiflex surgery have not been met. Therefore, we decided that the Plan does
not have to pre-approve Vertiflex surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the tracheal suction catheter and the skin barrier provided on September 2, 2020.
You asked the Plan to pay for the tracheal suction catheter and the skin barrier. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items were billed with incorrect modifiers.
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 codes A4624 and A5120 are not supported in the medical record. Specifically, these codes were not billed with modifiers. Code A4624 requires modifier NU and code A5120 requires modifiers AU and AV. This means these items were billed without the appropriate modifiers. Based on this information, we decided that Medicare rules for coverage of the tracheal suction catheter and the skin barrier have not been met. Therefore, we decided that the Plan does not have to pay for the tracheal suction catheter and the skin barrier provided on September 2, 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 this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated at a lower level of 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 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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee does not have a condition that requires treatment in a long-term acute care facility.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient appears to be improving and only requires short-term additional acute care services that could safely be completed at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the endodontic therapy, premolar tooth (excluding final restoration) (D3320).
You asked the Plan to pre-approve the root canal. You say that you are in great pain and need a root canal for tooth 21. The Plan denied your request. The Plan says a root canal has already been covered and additional root canals are not 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. The Plan covers one root canal per year. We looked at the file and Medicare rules. The record shows that the Plan has already covered one root canal in the year 2021. Based on this information, we decided that the Plan's rules for coverage of root canal have not been met. Therefore, we decided that the Plan does not have to pre-approve the endodontic therapy, premolar tooth (excluding final restoration) (D3320).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says Prolia is approved
under the enrollee's Part D benefit.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy. Since the
medication does not represent an expense to the physician and will not be included in the physician's bill, it is
not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Benefits for Prolia 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for an office visit (99213) provided December 1, 2020.
You asked the Plan to waive the copayment for the office visit. You say that the copayment should only be $5. The Plan denied your request. The Plan says that the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $5 copayment for specialist visits. The Plan says you must pay a $35 copayment for the office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $5 copayment for the office visit. Therefore, we decided that the Plan has to waive the copayment for an office visit (99213) provided December 1, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on November 20, 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 submitted records do not support the billing of code 29823.
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 29823 is arthroscopy, shoulder, surgical; debridement,
extensive.
We asked our coder 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 these services. Our reviewer says that the
submitted records do not support the billing of code 29823. Our coder reviewer found the submitted records
document that other arthroscopy procedures were performed. The records do not support the billing of a
surgical shoulder arthroscopy with debridement. Separate reporting of extensive debridement only applies to
CPT codes 29824, 29827, and 29828; therefore, 29823 is not eligible for separate billing or reimbursement
consideration.
We looked at this coder'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 pay for the surgical services rendered on November 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scans of the chest and of
the abdomen/pelvis.
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 the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has stage 3C colon cancer
diagnosed in March of 2019. The current guidelines support performing CT scans of the chest, abdomen, and
pelvis with contrast after completion of surgery and then annually for five years for the surveillance of stage II
to III colon and rectal adenocarcinoma. The clinical information provided does not describe this imaging time
frame. The CT scans are therefore not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve computed tomography (CT) scans of the chest and of the abdomen/pelvis.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (95940) provided on June 24, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
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 95940 is "Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (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 reviewer says that the use of CPT code 95940 is not supported by the records provided. Our coding reviewer found that the procedure report does not include description of where the monitoring took place, therefore this procedure cannot be verified. 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 not been met. Therefore, we decided that the Plan does not have to pay for the services (95940) provided on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the requested
provider.
You asked the Plan to pre-approve the physician's services. You say that this provider is highly recommended
by your primary care physician. The Plan denied your request. The Plan says a network gap does not exist.
These services are not urgent or emergent and can be provided in-network.
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve
physician's services to be provided by the requested provider.