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

We decided that the Plan does not have to pre-approve a bi-level positive airway pressure device (BiPAP),
humidifier, and related supplies.
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says a positive
airway pressure compliance report is needed.
The Plan follows Medicare rules. Medicare rules say that positive airway pressure devices are only covered
under certain medical indications.
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 requested items. Our physician
reviewer found that the enrollee has obstructive sleep apnea and was treated with CPAP starting in 2015. She
stopped using it some time ago but is having symptoms and wants to start again. She was given BiPAP
following a recent clinical visit because she reported occasional trouble exhaling with the CPAP. The records
do not include any compliance data or data on effectiveness of the CPAP in correcting the sleep disordered
breathing. A PAP titration in 2015 showed than CPAP was effective. BiPAP is considered not medically
necessary because CPAP has not been shown to be ineffective. The enrollee should have a trial of auto-CPAP
at home, with downloading of recorded data to determine compliance and effectiveness of CPAP. Therefore,
the requested services are not considered medically reasonable and 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 the requested items have not been met. Therefore, we decided that the Plan does
not have to pre-approve a bi-level positive airway pressure device (BiPAP), humidifier, and related supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you can complete 3 hours of therapy daily and still need physician oversight. The Plan denied your request. The Plan says the denial of IRF service is correct.
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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to currently tolerate 15 hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of 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 knee orthosis and the addition provided.

You asked the Plan to pay for the knee orthosis and the addition. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.

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 L1833 and L2397 are not supported in the medical record. Specifically, the
documentation does not include medical records showing that the prescribing physician ever saw the enrollee.
Based on this information, we decided that Medicare rules for coverage of the knee orthosis and the addition
have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and the
addition provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the chiropractor services rendered.

You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayments were applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for in-network Medicare-covered chiropractic services.

Review of the file shows that you had chiropractic services. The Plan reprocessed these claims to apply your contractual copayment. Per the contract with the Plan, there is a $20 copayment for in-network Medicare-covered chiropractic services. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $10.99 per date of service. Given that the allowed amount was less than the $20 copayment, you have been asked to pay $10.99 per date of service for these services, for a total of $21.98. Therefore, we decided that the Plan does not have to waive the copayments for the chiropractor services rendered.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF care provided to the enrollee from March 26, 2021, to April 2, 2021.
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 based on the documentation provided, the health plan's denial should be upheld. 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. 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 IRF care provided to the enrollee from March 26, 2021, to April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) and primary care office visit.

You asked the Plan to waive the copayment for EKG and office visit. You say that you were unaware that this provider was no longer your primary care provider. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct. The Plan also says that they have reduced the office visit copayment from $50 to the $20 primary care copayment.

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 $75 copayment for EKG and $20 copayment for primary care visit. For the EKG you have only been asked to pay the allowed amount of $20.86, which is less than the $75 copayment for diagnostic testing. Your total cost-sharing obligation is therefore $40.86.

You have been asked to pay less than $75 copayment for EKG and $20 copayment for primary care visit. EKG and office visit fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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 an electrocardiogram (EKG) and primary care office visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and pneumococcal polysaccharide vaccination services received on August 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit and pneumococcal polysaccharide vaccination services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON provider.
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 office visit and pneumococcal polysaccharide vaccination services received on August 17, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vacuum pump, residual limb volume management and moisture evacuation system (L5781) and alignable system (L5910).

You asked the Plan to pre-approve these services. You say that these items are medically necessary. The Plan denied your request. The Plan says that notes do not show why these items are medically necessary.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The medical notes do not clarify why the requested vacuum volume management system is needed or why your current alignable system cannot be used with the approved socket. Our physician reviewer found that your condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a vacuum pump, residual limb volume management and moisture evacuation system (L5781) and alignable system (L5910).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services.

You asked the Plan to pay for the SNF services. You say that the services 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 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 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) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that the enrollee is elderly and has trouble with finger sticks. It is felt that the CGM is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for this device.
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 or use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the dual-energy X-ray absorptiometry (DXA) bone density study provided on September 14, 2020.
You asked the Plan to pay for the dual-energy X-ray absorptiometry (DXA) bone density study. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation is missing required information.
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 77080 is dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine). We find that CPT code 77080 is not supported in the medical record. Specifically, no medical records were submitted to show how the enrollee came to the servicing provider, or whether the services were medically necessary. Based on this information, we decided that Medicare rules for coverage of the dual-energy X-ray absorptiometry (DXA) bone density study have not been met. Therefore, we decided that the Plan does not have to pay for the dual-energy X-ray absorptiometry (DXA) bone density study provided on September 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OmniSeq Advance Targeted Panel genetic testing.

You asked the Plan to pre-approve OmniSeq Advance Targeted Panel. You say that this testing 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 Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for OmniSeq Advance Targeted Panel. The Maximus Physician Reviewer determined that the use of next generation sequencing (NGS) or molecular profiling is recommended by the NCCN Guidelines for patients with endometrial cancer. Molecular analysis (eg, identification of characteristic translocations) can help classify difficult cases and provide future therapeutic targets. This enrollee has metastatic disease and is receiving first line therapy and her treating physician is planning for future recurrence. The service is reasonable and medically necessary. The Plan argues that OmniSeq far exceeds the recommendations of the guidelines. The Plan states a very small portion of this panel would be appropriate for this enrollee and the vast majority of the panel is not appropriate for endometrial cancer. The medical records show the enrollee is an 87-year-old woman with a diagnosis of poorly differentiated endometrial adenocarcinoma. On November 4, 2020, the enrollee was being considered for cycle 6 of Carboplatin 5 AUC and Paclitaxel. The prior authorization form for OmniSeq testing identified eight genes/targets of interest. 

Our Medical Director has concluded that the plan is correct in this case. The documentation supports that the OmniSeq Advance Targeted Panel exceeds the enrollee's medical need. NCCN notes that genetic testing and counselling should be considered for patients younger than 50 years of age with endometrial cancer and those with a significant family history of endometrial and/or colorectal cancer. Only eight genes/targets of interest were identified 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 OmniSeq Advance Targeted Panel. have not been met. Therefore, we decided that the Plan does not have to pre-approve OmniSeq Advance Targeted Panel genetic testing.
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 these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee was not admitted to the hospital and does not need these
services.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the setup of portable x-ray equipment and the transportation of portable x-ray equipment provided on September 22, 2020.

You asked the Plan to pay for the portable x-ray services. You say that Medicare guidelines show that these are billable and separately payable codes. The Plan denied your request. The Plan says the procedure code or bill type is inconsistent with the place of service.

The Plan must follow Medicare rules. Medicare rules say that POS code 31 is for patients who are in a Part A covered SNF stay. Medicare rules also say that the technical component of portable x-ray services during the course of a Medicare-covered stay in a SNF, are subject to consolidated billing and must be included on the SNF's Part A bill for the enrollee's covered stay. Medicare rules say that POS code 32 should be used with the services for beneficiaries in a noncovered stay. 

We looked at the file and Medicare rules. The case file shows that you billed this claim with a POS code of 31, for a covered SNF stay. If this were appropriately used, then the technical components of the portable x-ray services would be included in the SNF payment and not separately payable. If the SNF stay is not covered, then the POS code billed was not appropriate. Based on this information, we decided that Medicare rules for coverage of the portable x-ray services (as they were billed) have not been met. Therefore, we decided that the Plan does not have to pay for the setup of portable x-ray equipment and the transportation of portable x-ray equipment provided on September 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network exception for out-of-network home health
services.

You asked the Plan to pre-approve an in-network exception. The Plan denied your request. The Plan says there
are in-network providers within a reasonable distance that can provide services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that you receive your care from a provider who is eligible to provider services under Original
Medicare.

The requested provider in this case is not a network provider with the Plan, and is not eligible to provide
services under Original Medicare. 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 an in-network exception for out-of-network
home health services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hydrocodone-acetaminophen tablets.

You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan
denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not
covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug
benefits.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 hydrocodoneacetaminophen
tablets.

Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.