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

We decided that the Plan does not have to pay for the ambulance services provided on June 12, 2020.
You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 12, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 12, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a light device.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered for this condition.

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 the device. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found phototherapy is a standard of care for your condition. As in-office treatment is currently unavailable, the
device is reasonable.

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 device have been met. Therefore, we decided that the Plan has to pre-approve
a light device.

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: 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 stay is medically necessary. The Plan denied
your request. The Plan says the stay 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 in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
weakness, encephalopathy and multiple myeloma. Medical problems are stable. There are no complex nursing
or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. There is not a reasonable
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute IRF admission and services.
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 stay is medically necessary. The Plan denied your request. The Plan says the stay 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 in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for pneumonia and empyema. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance transport.

You asked the Plan to pay for non-emergent ambulance transport. You say that the services were necessary. The Plan denied your request. The Plan says prior authorization was not requested or received. Therefore, coverage criteria have not been met.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergent ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transport.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 3-month rental of CPAP device.

You asked the Plan to pre-approve the CPAP device. You say that you require the device. The Plan denied your request. The Plan says you did not use the PAP greater than four hours a night on at least 70% of the nights.

The Plan must follow Medicare rules. Medicare rules say that for a rental to be approved after a trial, the enrollee must demonstrate adherence to therapy. The enrollee did not demonstrate that they used the device in accordance with the adherence to therapy.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve the 3-month rental of CPAP device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray of the chest (CPT 71045) provided to the enrollee and billed under claim A.

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 Medicare billing criteria were not met. Maximus overturned the Plans denial stating the service provided was found to be necessary based on the medical records. The Plan requested a reopen and stated this was an administrative denial due to an error on the claim and not based on medical necessity. The Plan states that both providers belong to the same physician group and there was not a modifier -59 on the claim to show a separate and distinct service was provided.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. This claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for an x-ray of the chest (CPT 71045) provided to the enrollee and billed under claim A.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140).

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you do not understand
why this service was not covered. The Plan denied your request. The Plan says this service exceeds the
frequency limitation in your benefit plan.

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, problem focused limited oral
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem
focused limited oral evaluation (D0140), and your problem focused limited oral evaluation (D0140) benefit has 
been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited 
oral evaluation (D0140).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation.

You asked the Plan to waive the copayment for the ambulance transportation. You say that the ambulance traveled a short distance and as such the cost is too high. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 $350 copayment for ambulance services. 

You have been asked to pay a $350 copayment for the ambulance transportation. The ambulance transportation falls within the ambulance 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 ambulance transportation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya for the enrollee.
You asked the Plan to pre-approve Iluyma. You say that this drug is medically necessary. The Plan denied your
request. The Plan says the required step therapy criteria are not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated Maximus did not apply the correct criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. Our Medical Director looked at the case file and the reopen request. At issue is coverage
for Ilumya (Tildrakizumab-asmn). The Maximus Physician Reviewer determined that the medication was
medically necessary. The reviewer found there are limited options for this elderly enrollee with malignancy
history and need to avoid immunosuppressants in light of pandemic. The Plan argues that the required step
therapy alternative, Acitretin, is comparable to Ilumya in terms of safety and efficacy, as well as FDAapproved
indication. The medical records show that the enrollee is an 80-year-old man with a diagnosis of
widespread moderate to severe plaque psoriasis. The Plan denied coverage for Ilumya, stating that they provide
coverage for the drug when topical steroids, oral therapy (such as cyclosporine, methotrexate, acitretin) and
preferred therapy (such as Inflectra or Renflexis) have been tried and failed. The enrollee's dermatologist
writes states the enrollee is not able to use Inflectra or Renflexis due to skin cancer. The dermatologist also
writes that he will not prescribe oral medications due to the history of malignancy, and that he does not want
the enrollee on an immunosuppressant due to that and the COVID pandemic. However, our Medical Directer
has concluded that the Plan is correct in this case. The documentation does not support that Step Therapy
criteria were met in this case. The documentation does not support that the enrollee has tried and failed one
generic oral systemic medication such as acitretin. The documentation does not support that acitretin would
likely be less effective than Ilumya, or that acitretin would likely result in adverse effects 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 Iluyma have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transfer to another acute care hospital.
You asked the Plan to pre-approve transfer to another acute care hospital. You say that the transfer to another facility is necessary. The Plan denied your request. The Plan says the enrollee is receiving same services at the current level of care.
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 transfer to another acute care hospital. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that transfer to another acute care hospital is medically reasonable and necessary for the enrollee in this case. The enrollee is receiving acute hospital care, and acute care services have not been denied. There are no required medical services identified that are available at the proposed acute care hospital, that are not available at the current acute care hospital. The enrollee may remain in the current acute care hospital until a lower level of care is determined to be 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 transfer to another acute care hospital have not been met. Therefore, we decided that the Plan does not have to pre-approve transfer to another acute care hospital.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy provided by a participating provider.

You asked the Plan to waive the coinsurance for radiation therapy. You say that you are on social security and you cannot afford this coinsurance. The Plan denied your request. The Plan says the correct coinsurance 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 a 20% coinsurance for outpatient hospital services/radiation therapy.

You have been asked to pay less than a 20% coinsurance of the allowed amount for radiation therapy. You are being asked to pay less because you have reached your maximum out-of-pocket expense. The allowed amount is $10,653.20. The 20% coinsurance is $2,130.64 ($10,653.20 x 20% = $2,130.64). The total amount you are being asked to pay is $1,993.73. Radiation therapy falls within the outpatient hospital services/radiation therapy 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 radiation therapy provided by a participating provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray, portable x-ray equipment set up, and transportation of portable x-ray equipment provided by an OON provider.

You asked the Plan to pay for the chest x-ray, equipment set up, and transportation of x-ray equipment. You say that the diagnostic radiology procedures you are billing for does not require authorization. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the chest x-ray, portable x-ray equipment set up, and transportation of portable x-ray equipment provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services.

You asked the Plan to pay for the inpatient hospital services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were submitted untimely.

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 one calendar year after the date of service.

The record shows that a claim for the inpatient hospital services was not filed until October 26, 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 for the inpatient hospital services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural lysis adhesions (CPT code 62264), for the
enrollee.
You asked the Plan to pre-approve the services. You say that there is an adhesion on the enrollee's back
pressing on a nerve causing nerve pain radiating to the feet preventing the enrollee from walking. The Plan
denied your request. The Plan says this treatment of back pain by epidural adhesiolysis is considered
experimental, investigational, or unproven.
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 the services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this is considered an experimental/investigational procedure. Therefore, the request is deemed
not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve epidural lysis adhesions (CPT code 62264), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair accessory, power seat elevation (E2300).
You asked the Plan to pre-approve the power wheelchair accessory. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee meets the Medicare criteria for the repairs to the Group 3 PWC and Accessories with the exception of seat elevation feature, as this feature does not serve a primary medical function.
The Plan must follow Medicare rules. The rules say that a device that is not medical in nature is not covered. A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair accessory, power seat elevation (E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology physician services provided to the enrollee on September 4, 2019 under code 71045-26.
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 Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated this claim denied because the procedure code is inconsistent with the modifier billed for this service. The Plan states the service was billed with diagnosis code Z00.6 or encounter for examination for normal comparison and control in clinical research program. We found that modifier Q0 or Q1 is appropriate, as Z00.6 was billed as the primary diagnosis code for this service. The Medicare Claims Processing Manual , Chapter 32, Section 68.1, states practitioners must place a QV modifier (Item or service provided as routine care in a Medicare qualifying clinical trial) on the line for the device along with the IDE number. Effective for dates of service on or after January 1, 2008, practitioners will no longer bill a QV modifier to identify the device. Instead, practitioners will bill a Q0 (numeral 0 versus the letter O) modifier (Investigational clinical service provided in a clinical research study that is in an approved clinical research study) along with the IDE number. The Plan states that the claim required modifier Q0 or modifier Q1 for payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when necessary the appropriate modifiers. In this case, the claim submitted cannot be paid due to the omission of the required "Q" modifier. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for radiology physician services provided to the enrollee on September 4, 2019 under code 71045-26.