Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator provided on June 9, 2020.
You asked the Plan to pay for the services provided. You say that Medicare criteria has been met. The Plan denied your request. The Plan says the reasonableness of the provided durable medical equipment has not been established.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items ordered following the non-covered visit are likewise non-covered. Furthermore, the medical record does not contain sufficient documentation of the enrollee's medical condition to substantiate the necessity for the provided item. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator provided on June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cancer panel provided on June 30, 2020.
You asked the Plan to pay for the gene panel. The Plan denied your request. The Plan says to report comprehensive genomic profile testing, service providers should use code 81479.
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 looked at the file and the rules. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the hereditary cancer panel provided on June 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care.

You asked the Plan to pre-approve inpatient hospital care. You say that these services are medically necessary. The Plan denied your request. The Plan says that it is not necessary for you to stay in the hospital after this 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 inpatient hospital care. Our reviewer says that inpatient hospital care is not medically reasonable and necessary. There is no clinical rationale for inpatient level of care services. A unilateral total knee arthroplasty may be performed at an outpatient level of care which provides 23 hours post recovery unit to monitor post-operative clinical condition. If stable postoperatively, you may be transitioned to a less intense setting to continue her recovery. If unstable postoperatively, requiring additional treatment and monitoring, the treating physician may order a change to inpatient place of service with documentation of the clinical rationale. The review indicates that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital care.
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 the records provided support the need for IRF care. The Plan denied your request. The Plan says the medical records do not show that the enrollee has functional limitations. The Plan says that the criteria for coverage of IRF care have not been met.

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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical treatment of a bladder mass. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical necessity for continuing these services.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for your condition. You have had extensive therapy for this condition and the documentation does not indicate that her functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. You have been educated in a home exercise program. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine physical exam provided on October 23, 2020.
You asked the Plan to pay for the exam. You say that it was your error in making another appointment for a
physical. The Plan denied your request. The Plan says the benefit for the service has been exhausted.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
We looked at the file and the rules. The records show that you last received a physical on January 21, 2020.
Your plan only covers a physical once per calendar year. Based on this information, we decided that the rules
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the routine
physical exam provided on October 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid services provided on September 10, 2020.
You asked the Plan to pay for the services provided. You say that your hearing loss is a medical condition. The
Plan denied your request. The Plan says there is no additional benefit that covers more than the allowance.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
We looked at the file, and the Plan's rules. The file shows that the total cost billed for the hearing aid services
was $12,647.60. Your plan only pays up to $1000 every three years for hearing aids. This means that any
amount over the plan-allowed $1000 is your responsibility. Based on this information, we decided that the
Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to further pay
for the hearing aid services provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from September 3, 2020, through
September 10, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 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 physician's services provided from September 3, 2020, through September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urinary stent procedure.

You asked the Plan to waive the copayment for the surgery services. You say that you need an itemized bill of what is not covered by Medicare and what is the $50 copay for. This was a stent that was done and kept overnight for observation. The Plan denied your request. The Plan says the claim was corrected and the amounts for $79.88 for self-administered medication and the second copay of $25 has been removed and the correct copay 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). Your contract with the Plan clearly says that you must pay $25 copayment for surgery services in an outpatient hospital.

You have been asked to pay $25 copayment for the surgery services. The surgery services fall 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 urinary stent procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed services cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for the orthoses.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (80307 and G0483) provided on March 11, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim submitted indicates that the specimen was collected in a laboratory place of service; however, the medical documentation indicates the specimen was collected in an office setting.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT codes 80307 and G0483 are not supported in the record. Specifically, the claim submitted suggests that the specimen was collected in a laboratory place of service. The documentation submitted indicates that the face-to-face evaluation was rendered in an office setting. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (80307 and G0483) provided on March 11, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan does not have to pre-approve Opdivo (J9299) for the enrollee.
You asked the Plan to pre-approve Opdivo (J9299). You say that Opdivo is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus applied the incorrect criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Opdivo (Nivolumab). The Maximus Physician Reviewer determined that there is evidence in triple negative PD L1 metastatic breast cancer that Opdivo can be of benefit. Given the diagnosis, the window for therapy is small. The treatment is indicated. The Plan argues that there is no evidence to support the use of Opdivo for the enrollee in this case. Our Medical Director says that the enrollee has a diagnosis of triple negative breast cancer. Testing was positive to PD-L1. Our Medical Director has concluded that the Plan is correct in this case. The documentation does not support that Opdivo is medically reasonable and necessary, and that it is expected to be safe and effective for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo (J9299) have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo (J9299) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that 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 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. 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 were admitted for COVID-19 pneumonia and pulmonary embolism. Your medical conditions are stable. There are no medical needs requiring inpatient admission. 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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. Our physician reviewer found that your 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the suspension sleeve for lower extremity orthosis (L2397) and knee orthosis, adjustable knee joints (L1833) provided on September 14, 2020.
You asked the Plan to pay for the suspension sleeve for lower extremity orthosis and knee orthosis, adjustable knee joints. You say that the items provided were medically necessary. The Plan denied your request. The Plan says there is no indication the enrollee ever had an examination with the provider.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis with adjustable ankle joints is covered if the enrollee has knee instability which must be documented by examination of the beneficiary and objective description of joint laxity. 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 the suspension sleeve for lower extremity orthosis and knee orthosis, adjustable knee joints. Our reviewer says that the items provided were not medically reasonable and necessary. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, he item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 suspension sleeve for lower extremity orthosis and knee orthosis, adjustable knee joints have not been met. Therefore, we decided that the Plan does not have to pay for the suspension sleeve for lower extremity orthosis (L2397) and knee orthosis, adjustable knee joints (L1833) provided on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone graft (D7953).

You asked the Plan to pay for the bone graft. The Plan denied your request. The Plan says this 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 services are not among
those covered under this benefit. The Plan covers only those dental services for which the codes are listed in
the Evidence of Coverage. Dental code D7953 is not listed, and therefore is not covered. Therefore, we decided
that the Plan does not have to pay for the bone graft (D7953).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care.

You asked the Plan to pay for the SNF services. You say that the services provided to the enrollee are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee had returned to her prior baseline level of function and did not have skilled nursing needs. The Plan also says that the services were not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care.