Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3320) provided on November 10, 2020.
You asked the Plan to pay for the endodontic therapy. You say that you would like this service to be covered. 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 endodontic therapy (D3320) provided on November 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro 2, Motion G orthotic device to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a MyoPro 2, Motion G orthotic device to be provided by an OON provider. You say that the item is necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide this item. Therefore, coverage criteria have not been met.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a MyoPro 2, Motion G orthotic device to be provided by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana.
You asked the Plan to pre-approve Brovana. You say that the medication is necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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.
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 Brovana. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found the enrollee has not tried and failed the
plan's step one agent. The prescriber has not addressed why the plan's preferred solution agent, Perforomist, is
not appropriate for the enrollee. The elements of the coverage rule are not satisfied. The requested service
cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Brovana have not been met. Therefore, we decided that the Plan does not have
to pre-approve Brovana.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 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 the accessories. 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 reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities supports that the enrollee can control any power options through their own individual switches. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (ECG) interpretation (93042) provided November 3, 2020.
You asked the Plan to pay for the ECG interpretation. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not separately payable.
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 93042 is ECG rhythm interpretation. We find that CPT code 93042 is not supported in the medical record. Specifically, the documentation does not include a separate report for the ECG strip interpretation. A simple interpretation of an ECG is included in the Emergency Room E/M service. Based on this information, we decided that Medicare rules for coverage of the ECG interpretation have not been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (ECG) interpretation (93042) provided November 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the occupational therapy (OT) services rendered from October 26, 2020 to December 24, 2020.
You asked the Plan to waive the copayment for these services. You say that you received a letter that said all copayments would be waived through December 31, 2020. 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 $40 copayment for Medicare-covered physical, occupational, and speech therapy visits.
Review of the file shows that you received OT services from October 26, 2020 to December 24, 2020. You have been asked to pay a $40 copayment per visit for these services. These services fall within the Medicare-covered physical, occupational, and speech therapy visits 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.
The copayment waiver sent by the Plan does not include OT services. Therefore, we decided that the Plan does not have to waive the copayment for the occupational therapy (OT) services rendered from October 26, 2020 to December 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip x-ray provided to the enrollee September 8, 2020 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 are not met. The IRE overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan stated that Claim A denied because the Plan had already paid for this service under another claim. The Plan states the NPI website shows that both providers are listed as Diagnostic Radiology Specialists and both providers work within the same professional practice or group. The Plan states the correct billing of this service needed to include modifier 59 to establish a separate and distinct service was provided. 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. Based on the documentation provided, 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 the hip x-ray provided to the enrollee September 8, 2020 and billed under Claim A.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided to the enrollee on September 2, 2020 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 are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan stated that Claim A denied because the Plan had already paid for this service under another claim. The Plan states the NPI website shows that both providers are listed as Diagnostic Radiology Specialists and both providers work within the same professional practice or group. The Plan states the correct billing of this service needed to include modifier -59 to establish a separate and distinct service was provided. 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. Based on the documentation provided, 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 the chest x-ray provided to the enrollee on September 2, 2020 and billed under Claim A.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided to the enrollee on May 25, 2020 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 the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan stated that Claim A denied because the Plan had already paid for this service under another claim. The Plan states the NPI website shows that both providers are listed as Diagnostic Radiology Specialists and both providers work within the same professional practice or group. The Plan states the correct billing of this service needed to include modifier -59 to establish 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. Based on the documentation provided, 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 the chest x-ray provided to the enrollee on May 25, 2020 billed under Claim A.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, basic life support, without ambulance transport (A0429) provided October 16, 2020.
You asked the Plan to pay for the basic life support without ambulance transport service. You say that you feel the charges are excessive. The Plan denied your request. The Plan says without a transport there is no payable service.
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 October 16, 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 service, basic life support, without ambulance transport (A0429) provided October 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The
Plan denied your request. The Plan says rules for LTACH care have 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 that the enrollee is a 77-year-old female who was admitted to the hospital on April
30, 2021, for intractable seizure and acute respiratory failure requiring intubation. Her hospital course has been
notable for hypertensive urgency and empiric treatment for endocarditis. There is no documentation provided
necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care
facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital
where she 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from November 2, 2019, to November 5, 2019, and billed with DRG 871.

You asked the Plan to pay for inpatient care billed with DRG 871. You say that the billed DRG is correct. The Plan denied your request. The Plan says the records support DRG 194 instead of 871.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with DRG 871, septicemia or severe sepsis without mechanical ventilation greater than 96 hours with major complications or comorbidities. 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 inpatient care billed with DRG 871. Our reviewer says that the billed DRG is not supported.

Our physician reviewer found the enrollee was admitted with pneumonia and the principal diagnosis was recorded as A41.9 Sepsis, Unspecified Organism. At the time of admission, the enrollee had a fever and was tachycardiac. He recently suffered rib fractures. The white blood cell count was normal. His cultures were negative, and his chest x-ray was consistent with pneumonia or atelectasis. The record does not support that the condition responsible for the patient's admission established after study that occasioned the admission was sepsis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient care provided from November 2, 2019, to November 5, 2019, and billed with DRG 871.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on December 18, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy or by Medicare.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99213) provided on December 18, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Rituximab.
You asked the Plan to pre-approve Rituximab. You say that the enrollee has had the drug when he had other
insurance. The Plan denied your request. The Plan says that the drug is not approved for the enrollee's
condition.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
Medical records were requested, but not provided by the Plan. The Plan has not made reasonable and diligent
efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we
decided that the Plan has to pre-approve Rituximab.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for computed tomography (CT) Abdomen & Pelvis (74177)
You asked the Plan to pay for the CT scan. You say that the enrollee had a CT scan completed 10/13//2015 that showed liver and pancreatic lesions. He has not had any follow up imaging since that time and this scan would give the follow up needed. The Plan denied your request. The Plan says that this service is not reasonable and necessary as alternate advanced imaging would be more appropriate.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 pay for the CT scan. Our reviewer says that the requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee meets criteria for a repeat follow up CT scan of chest and abdomen to assess current status of the liver and pancreatic lesions. The current CT scan results can then be compared to that of 2015. If further evaluation and workup is needed, MRI can be considered after. 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 CT scan have been met. Therefore, we decided that the Plan has to pay for computed tomography (CT) Abdomen & Pelvis (74177)
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve outpatient mental health services (99213, 90833) provided May 26, 2018 to July 1, 2020.
You asked the Plan to pre-approve the outpatient mental health services. You say that you were given incorrect information about the timeline to submit a claim. additionally, the Evidence of Coverage says you do not need prior approval for out-of-network care. The Plan denied your request. The Plan says that some of the claims were filed untimely. Additionally, the out-of-network specialist visits were not pre-authorized.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Evidence of Coverage states on page 57 that pre-authorization is not required to obtain out-of-network services. Page 123 states that prior authorization for outpatient mental health services "may" be required. The Evidence of Coverage is ambiguous, and it is not clear if prior authorization is REQUIRED for these services or not. The denial letter provided to the IRE by the plan does not detail or explain the reason for denial. The plan did not provide any documentation of when the claims were received or any documentation that it addressed the enrollee's claim that she was provided incorrect information about the timeframe to submit claims. Therefore, we decided that the Plan has to pre-approve outpatient mental health services (99213, 90833) provided May 26, 2018 to July 1, 2020.