Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says your needs can be met at a different 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 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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the medical records provided It is not clear you would be able to fully benefit and/or participate in an IRF level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decidedthat Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency ambulance transportation (A0427) received on May 08, 2020.You asked the Plan to waive the copayment forthe emergency ambulance transportation. You saythat you were admitted to the hospital after being transported via ambulance sothecopay should be waived.The Plan denied your request. The Plan says you were under evaluation in the Emergency Room for two days before being discharged. You were not admitted to the hospital; therefore, the ambulance copay was not waived.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 $200 copay for ambulance services.You have been asked to pay a $200 copayment for ambulance services. This service falls within the ambulance transportation 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 forthe emergency ambulance transportation (A0427) received on May 08, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous vertebral kyphoplasty.
You asked the Plan to pre-approve the kyphoplasty. You say that this treatment is the best option for the
enrollee's condition. The Plan denied your request. The Plan says this compression fracture appears to be
healed and chronic which means that this surgery is not likely to be helpful.
The Plan follows Medicare rules. Medicare rules say that PVA may be covered for the treatment of acute or
subacute vertebral compression fractures.
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 kyphoplasty. Our reviewer says that
the requested treatment is not considered medically reasonable and necessary. Our physician reviewer found
percutaneous vertebral augmentation is typically considered not medically necessary in conditions that are
considered chronic. The 11/21/2020 CT scan report opined findings of a subacute L2 compression fracture. The
01/03/2021 CT scan noted revealed compression fractures with chronic deformity at the T12 and L1 levels. The
findings of L2 compression fracture (despite the reported increased compression deformity at 30%) would be
considered chronic. Painful back findings are plausibly attributable to multiple chronic compression-fractured
vertebrae. Therefore, the requested vertebroplasty would not be considered necessary or appropriate.
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 kyphoplasty have not been met. Therefore, we decided that the Plan does
not have to pre-approve a percutaneous vertebral kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe infusion services rendered on July 13, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 96365, 96375, and 96366 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 96365 is intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96375 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure). The definition of code 96366 is intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure).We find that CPT code 96365 is not supported in the medical record. Specifically, there is no documentation of intravenous infusion, up to one hour. Given that the primary procedure code 96365 is not supported, add-on codes 96375 and 96366 are also not supported. 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 forthe infusion services rendered on July 13, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D2740, D2950) for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.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 Plandoes not haveto pre-approvedental services (D2740, D2950) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140) provided on October 5, 2020.You asked the Plan to pay forthe dental service. You say that you had a consult with an oral surgeon on the date of service in this case. You say that you had an extraction done on October 26, 2020. You say that you were not advised that the extraction would not be covered.The Plan denied your request. The Plan says 2 oral exams are covered per calendar year. The Plan also says that the frequency limit has been exceeded.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 frequency limit of 2 oral exams per calendar year has been exceeded. The record shows that the Plan paid for the oral exams that you received on January 28, 2020, and July 20, 2020.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140) provided on October 5, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDaliresp tab.You asked the Plan to pre-approveDaliresp tab. You say that you want the enrollee treated with this drug.The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit.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-approveDaliresp tab.Benefits for Daliresp tabmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Favorable

We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on
February 17, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care. Maximus
overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says
that both the ordering provider and the lab were out of network. The enrollee did not have prior authorization
for out of network care and this lab service resulted from an order from and out of network provider.
The Plan is correct in this case. 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 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 out of network lab services provided to the enrollee on February 17, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay forthe paramedic intercept services provided to you on July 20, 2020.You asked the Plan to pay forthe services. You say that the services should be covered.The Plan denied your request. The Plan says that the services were not provided in a rural area.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.You were provided the services by a contract provider. The file does not show that the Plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the Plan. You were provided the services with the reasonable expectation that the services would be covered under your plan.Therefore, we decided that the Plan has to pay forthe paramedic intercept services provided to you on July 20, 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 toopen the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira inj.
You asked the Plan to pre-approve Humira inj. You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit.
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 Humira inj.
Benefits for Humira inj 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waivethe deductible for the diagnostic colonoscopy you received on October 28, 2020.You asked the Plan to waivethe deductible. The Plan denied your request. The Plan says the deductible was not met.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 there is a $750 deductible you have to pay out-of-pocket before the Plan will pay its share for your covered medical services. Review of the file shows that you had a diagnostic colonoscopy on October 28, 2020. The colonoscopy falls within the outpatient surgery benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible you have to pay out-of-pocket before the Plan will pay its share for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time the colonoscopy was received on October 28, 2020.Therefore, we decided that the Plan does not have to waivethe deductible for the diagnostic colonoscopy you received on October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3330) for tooth # 30.
You asked the Plan to pre-approve the dental service. You say that this should be covered. The Plan denied your request. The Plan says 1 root canal per calendar year is covered. The Plan says that the frequency limit has been reached.
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 frequency limit of 1 root canal per calendar year has been reached. The record shows that the Plan approved a root canal for tooth # 18. Therefore, we decided that the Plan does not have to pre-approve a root canal (D3330) for tooth # 30.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided on August 28, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than onecalendar year after the date of service.The record shows that a claim for the services was not filed until September 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe services provided on August 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda 100mg/4ml injectable 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 the requirements are not met.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Pembrolizumab is FDA approved for the treatment of advanced endometrial carcinoma (in combination with lenvatinib) that is not microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) in patients who have disease progression following prior systemic therapy and are not candidates for curative surgery or radiation. There is no documentation of MSI testing and this enrollee has not received any prior therapy for her metastatic endometrial cancer. There is no medical literature available to support 1st line use. The service is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda 100mg/4ml injectable for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approvecontinued inpatient hospital care after January 31, 2021.You asked the Plan to pre-approvecontinued inpatient care. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested services are not medically necessary.The Plan must follow Medicare rules. Before discharging an enrollee from an inpatient hospital level of care, Medicare rules say that the Plan must obtain concurrence from the physician who is responsible for the enrollee's inpatient care.In this case, the record does not show that the physician responsible for the enrollee's inpatientcare concurs with this discharge.Therefore, we decided that the Plan has to pre-approvecontinued inpatient hospital care after January 31, 2021.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Cxbladder testing rendered on July 6, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing isnot covered.The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered.The test at issue is CxBladder. This test is not covered by Medicare.Therefore, we decided that the Plan does not have to pay forthe Cxbladder testing rendered on July 6, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 14, 2020 and July 16, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 the laboratory services are not supported in the medical record. Specifically, these services were billed with place of service 22 (outpatient and a modifier of 26 (professional component). The billed laboratory services are ineligible for separate payment as payment is considered part of the hospital Prospective Payment System (PPS) rate. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 14, 2020 and July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 93042) provided on July 8, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this is 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 requested services 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 services have not been met.Therefore, we decided that the Plan does not have to pay forthe services (CPT 93042) provided on July 8, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere are no complete or long-term care needs identified.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-approvethe LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does notrequire services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of theLTACH services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe copayment for the office visits you had on April 2, 2020, and August 16, 2020.You asked the Plan to waivethe copayment. The Plan denied your request. The Plan says you are responsible for the cost share.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 copayment for Medicare-covered vision services at a specialist's office. Review of the file shows that you were provided vision services on April 2, 2020, and August 16, 2020. You have been asked to pay a $5 copayment for each of the visits. The services fall within the vision 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 waivethe copayment for the office visits you had on April 2, 2020, and August 16, 2020.