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

We decided that the Plan does not have to waive the copayment for the emergency department visit (99283) provided September 28, 2020.

You asked the Plan to waive the copayment for the emergency department visit. You say that you would like this copayment waived. The Plan denied your request. The Plan says the copayment processed correctly in this case.

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 $50 copayment for emergency services. 

You have been asked to pay a $50 copayment for the emergency department visit. This service falls within the emergency 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 emergency department visit (99283) provided September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on October 21, 2020.

You asked the Plan to pay for the scaling. You say that this service was a preventive treatment. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on October 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (64625).

You asked the Plan to pre-approve radiofrequency ablation. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is considered experimental/ investigational.

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 radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is considered an experimental/ investigational procedure because of the wide variation in efficacy in the peer reviewed literature. Therefore, the request is considered 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 radiofrequency ablation have not been met. Specifically, this service is considered experimental/ investigational. This means that it is not medically necessary or reasonable and is not covered under the enrollee's benefit plan. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (64625).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy for a molar tooth (D3330).

You asked the Plan to pre-approve the root canal for molars. You say that you had to get a molar filled 3 times, and each time the filling has fallen out. You say that the molar on the other side has a hole in it that accumulates food. You say that you have been in a lot of pain and have to take medicine to ease the ache. You say that your dentist has advised you that the requested root canal is necessary for both back molars. The Plan denied your request. The Plan says the service in dispute is not a covered benefit under our contract.

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 Plan does not have to pre-approve endodontic therapy for a molar tooth (D3330).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the evaluation, testing, and programming adjustment of permanent dual lead pacemaker system (93280) provided October 7, 2020.

You asked the Plan to waive the copayment for the evaluation, testing, and programming adjustment of permanent dual lead pacemaker system. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the copayment has processed correctly in this case.

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 specialist services. 

You have been asked to pay a $20 copayment for the evaluation, testing, and programming adjustment of permanent dual lead pacemaker system. The services provided falls within the specialist 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 evaluation, testing, and programming adjustment of permanent dual lead pacemaker system (93280) provided October 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that your care needs could be met with either to a skilled nursing facility or
home with home health.

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 weakness and falls and was
treated for lower extremity cellulitis and acute on chronic congestive heart failure. 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: 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 a lower level of care cannot provide the
interdisciplinary approach needed. The Plan denied your request. The Plan says the enrollee does not require an
intensive, complex, multidisciplinary approach to daily therapy.

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 physician reviewer found
that the enrollee was admitted to the acute hospital for a fall, chest pain and hypotension. She was treated with
a leg immobilizer for a non-displaced femur fracture and received antibiotics for lower extremity cellulitis. Her
medical conditions are stable. There are no medical needs requiring an inpatient admission. There are no
complex nursing needs. While the medical record documents a need for physical and occupational therapy, it
does not document a need for an intensive rehabilitation program.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic bone marrow; aspiration provided on August
10, 2020.

You asked the Plan to pay for diagnostic bone marrow; aspiration (38220). You say that the Plan should pay
this claim. The Plan denied your request. The Plan says the clinical value and effectiveness of the bone marrow
aspirate in the setting of subtalar fusion surgery have not been demonstrated in the peer reviewed literature.

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 pay for diagnostic bone marrow; aspiration (38220).
Our reviewer says that the procedure is not considered medically reasonable and necessary in this case. Our
physician reviewer found bone marrow aspiration remains experimental in cases of spinal fusion. More
research is needed to show safety and efficacy. Iliac crest bone graft is the gold standard.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of diagnostic bone marrow; aspiration (38220) have not been met. Therefore, we
decided that the Plan does not have to pay for the diagnostic bone marrow; aspiration provided on August 10,
2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have non-emergency BLS ambulance services (A0428) provided September 1, 2020.

You asked the Plan the ambulance services. You say that please review your appeal based on the medical necessity criteria listed, along with the enclosed medical documentation and consider your claim for payment. The Plan denied your request. The Plan says the records do not support the medical necessity of the requested service.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 ambulance services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee in this case requested ambulance transportation services for attending her radiation treatment appointment. The documentation does not suggest that a stretcher van would be contraindicated in any way. There was no noted need for expertise or special equipment during transportation. The documentation does not support the medical necessary of ambulance transportation on 9/1/2020. 

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 ambulance services have not been met. Therefore, we decided that the Plan does not have non-emergency BLS ambulance services (A0428) provided September 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 13, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are considered global.

The Plan must follow Medicare rules. Medicare rules say that when a physician performs a diagnostic test under arrangement to a hospital and the test and the interpretation are not separately billable, the interpretation cannot be billed by the physician. 

We looked at the file and Medicare rules. The services in question are considered global and separate payment for the physician interpretation is not allowed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient room and board.

You asked the Plan to waive the copayment for the inpatient room and board. You say that this was one
continuous inpatient stay for the same medical condition. The Plan denied your request. The Plan says you
were transferred to a separate facility and that this stay is considered a new admission.

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 $295
copayment for each day, for days 1 to 5 for Medicare-covered hospital care. The contract also states that this
cost-sharing obligation applies each time you are admitted to the hospital.

You have been asked to pay a total of $1180 in copayments, a $295 copayment for each of four days, for the
inpatient room and board. The inpatient room and board fall within the inpatient hospital 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 waive the copayment for the inpatient room and board.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve continued services. You say that you cannot stand very well. The Plan denied your request. The Plan says you no longer require daily skilled services.

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 pre-approve continued services. Our physician reviewer found that from a nursing perspective, you received oral medications, and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at a moderate assist level with transfers. You required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness, or intensity of service criteria for 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80307, G0482) provided on April 6, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim indicates that the laboratory specimen was obtained in a laboratory setting; however, the medical documentation submitted indicates the specimen was collected in an office setting.

The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. For example, if the physician's face-to-face encounter with a patient occurs in the office, the correct POS code on the claim, in general, reflects the 2-digit POS code 11 for office. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the claim indicates that the specimen was collected in a laboratory setting, but the medical record indicates that the face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (80307, G0482) provided on April 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).

You asked the Plan to pre-approve Keytruda. You say that the service is medically necessary. The Plan denied
your request. The Plan says the drug/regimen is not being prescribed for a medically-accepted indication.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Keytruda. Our reviewer says that the
service is not medically necessary. Our physician reviewer found that the requested use of Keytruda is not
FDA-approved for the enrollee's diagnosis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Specifically, the requested drug is not FDA
approved for the enrollee's diagnosis. This means the drug is not medically necessary or reasonable. Therefore,
we decided that the Plan does not have to pre-approve Keytruda (J9271).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omeprazole Cap.

You asked the Plan to pre-approve Omeprazole Cap. 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 Omeprazole Cap.

Benefits for Omeprazole Cap 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on February 19, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says assistant surgeon services are not covered for this procedure.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 39402. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on February 19, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pre-approve a destruction of Paravertebral Facet Joint Nerve procedure for the enrollee.

You asked the Plan to pre-approve this procedure. You say that this treatment is medically necessary. The Plan denied your request. The Plan says the Medicare LCD criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct LCD criteria.

Our Medical Director looked at the case file and the reopen request. Our Medical Director says at issue is coverage for the destruction of a paravertebral facet joint nerve procedure. The Maximus Physician Reviewer determined that the enrollee had evidence of cervical facet joint disease and had failed reasonable and/or conservative treatment. It was determined that the enrollee met the Medicare covered indications for the requested procedure. The Plan requested a reopen and stated the medical records do not support that the enrollee experienced temporary or prolonged abolition of his pain after a facet joint nerve block injection. The medical records show the enrollee has a diagnosis of neck pain with spondylosis in the cervical region, without myelopathy or radiculopathy.

The physician note documents that the enrollee had relief of 60 to 70% during the anesthetic phase of diagnostic medial branch blocks on August 10, 2020 and had returning pain on September 8, 2020. Our Medical Director has concluded that the Plan is correct in this case. The medical record documentation does not support that the enrollee experienced temporary or prolonged abolition of the pain after a facet joint nerve block injection which indicates the Medicare LCD criteria are not met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction of Paravertebral Facet Joint Nerve for the enrollee.