Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular radiofrequency ablation.
You asked the Plan to pre-approve genicular radiofrequency ablation . You say that you would like reconsideration because this service has been approved in the past and has been helpful. The Plan denied your request. The Plan says there is a lack of literature with true head-to-head comparisons to other standard treatments.
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 genicular 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 is considered an experimental/investigational procedure that is subject of ongoing clinical trials. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular radiofrequency ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve the home sleep test.
You asked the Plan to pre-approve the home sleep test. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says that home sleep testing is not covered for persons with comorbidities.
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 home sleep test. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the member has no contraindications to the use of a home sleep test as defined in the LCD or current practice guidelines. 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 home sleep test have been met. Therefore, we decided that the Plan has to pre-approve the home sleep test.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an assisted living visit provided to the enrollee on October 9, 2019.
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 this claim was not filed timely. Maximus overturned the Plans denial stating a claim could be submitted within 365 days. The Plan requested a reopen and stated that Per CMS guidelines, MMP encounter timeliness submissions differ from Medicare Advantage submission. Encounters should be submitted 180 days from the date of service for MMP plans and the enrollee is an MMP member. The Plan included the guidance CMS.gov that explains this as additional information.
The Plan is correct in this case. The Plan follows Medicare rules. The rules say that for claims regarding services furnished to MMP members, the claims must be filed within 180 days of the date of service. The record shows that this claim was not filed within 180 days of the date of service. Therefore, we decided that the Plan does not have to pay for an assisted living visit provided to the enrollee on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing services provided to the enrollee on February 17, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim denied because the provider was not eligible for payment of this service. The NPI Registry website shows this provider is registered with a taxonomy for a Nurse Practitioner. However, the provider did not bill with this taxonomy. The Plan provided additional pages of the claim that show the provider billed with a Registered Nurse taxonomy. Medicare billing criteria are not met.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid due to an issue with the taxonomy code reported. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for nursing services provided to the enrollee on February 17, 2020. .
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan.
You asked the Plan to pre-approve an MRI scan. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested MRI is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI scan. Our reviewer says that
the documentation does not support that the requested MRI scan is medically reasonable or necessary. Our
physician reviewer found the enrollee has reported low back pain with radiation of symptoms, but worse with
sitting and bending at waist or other movement such as getting into or out of a car. Physical therapy was
recommended but not yet started. There are no documentation of bowl or bladder changes. The enrollee has not
yet tried, and failed conservative treatments including physical therapy and does not exhibit any signs of a red
flag diagnosis that might warrant more urgent MRI. Therefore, the enrollee does not meet criteria for the
requested 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 an MRI scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve a magnetic resonance imaging (MRI) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the walking boot.

You asked the Plan to waive the deductible for the walking boot. You say that you cannot find anything that indicates you owe a deductible for durable medical equipment. The Plan denied your request. The Plan says the deductible applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $185. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Your contract with the Plan says that after you have paid the annual deductible you pay a 17% coinsurance for Medicare-covered durable medical equipment and related supplies.

The item or service you asked the Plan to waive the deductible for falls within the "Durable Medical Equipment (DME) and related supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $185 deductible applies to durable medical equipment. This cost sharing is a contractual obligation that had not been met at the time the walking boot. Therefore, we decided that the Plan does not have to waive the deductible for the walking boot.
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. 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 in the Medicare rules section are met. Custodial care is not covered. Continued SNF services beyond March 11, 2021, were requested. 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 you are at a maximal assist level for bed mobility, transfers, eating, and upper body dressing. You are at total assist for bathing, lower body dressing, and toileting. You do not have documented skilled nursing or therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you want to be moved to a Long Term Care Facility to receive the rehabilitation assistance you are needing. The Plan denied your request. The Plan says you do not meet the requirements for LTACH services.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous transluminal coronary angioplasty (92920).

You asked the Plan to pre-approve a percutaneous transluminal coronary angioplasty. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is not medically reasonable and 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 a percutaneous transluminal coronary angioplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has a diagnosis of peripheral vascular disease, unspecified, and presented to the vascular health clinic for evaluation of right lower extremity discomfort. It was documented that the enrollee had disabling right lower extremity claudication, with rest pain that wakes her at night. The enrollee does not have a covered indication for a percutaneous transluminal coronary angioplasty. The documentation in the case file does not support the medical necessity of a percutaneous transluminal coronary angioplasty. Rather, the documentation supports that a peripheral percutaneous transluminal angioplasty is what would be indicated 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 a percutaneous transluminal coronary angioplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous transluminal coronary angioplasty (92920).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an overbed table (E0274).
You asked the Plan to pre-approve an overbed table. You say that you would like this item covered. The Plan denied your request. The Plan says this item is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an overbed table (E0274).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa.

You asked the Plan to pre-approve Vascepa. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

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 Vascepa.

Benefits for Vascepa 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 shoulder surgery provided by an out-of-network provider.

You asked the Plan to pay for shoulder surgery. You say that the enrollee was referred by their primary care
physician and were informed no prior authorization was needed. You say that the physician performed the
surgery in good faith and should be compensated. The Plan denied your request. The Plan says contracted
providers were available to perform the services.

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 shoulder surgery provided by an out-of-network
provider.
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 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 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. 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 rib fractures and Achilles
Tendon rupture after a fall and for pneumonia. Your 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. 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: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the office visits. We decided that the Plan does not
have to waive the copayment for acupuncture treatment.
You asked the Plan to waive the copayment for acupuncture treatments and office visits. The Plan says that the
copayments applied correctly.
We decided that the Plan has to waive the copayment for the for the office visits.
The provider in this case is not considered a medical practitioner according to Medicare or considered a
specialist. This means that the specialist copayment is not justified by the Plan contract. Therefore, we decided
the Plan has to waive the copayment for the office visit provided on August 11, 2020, and August 18, 2020
We also decided that the Plan does not have to waive the copayment for acupuncture treatment.
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 $45
copayment for up to 4 visits per year for massage therapy and acupuncture. Therefore, we decided that the Plan
does not have to waive the copayment for acupuncture treatment provided on August 11, 2020, and August 18,
2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing services (80307).

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 that CPT code 80307 is redundant as CPT code G0483 has been approved.

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 80307 is Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service.

We asked our coder 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 drug testing services. Our reviewer says that CPT code 80307 meets criteria for billing and reimbursement consideration. Our reviewer found reporting CPT 80307 with HCPC G0483 is appropriate as CPT 80307 is a presumptive laboratory test, and HCPCS G0483 is definitive.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have been met. Therefore, we decided that the Plan has to pay for drug testing services (80307).

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.