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

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 3, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.

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 the various denied CPT codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 laboratory services provided to the enrollee on August 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inversion table.
You asked the Plan to pre-approve an inversion table. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered by Medicare.
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 inversion table.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on July 10, 2020.
You asked the Plan to pay for foot orthotics. You say that this prevents more back and knee problems. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on July 10, 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 for the enrollee.
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 the enrollee's 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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for sepsis and left lower quadrant pain. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve all lower extremity prostheses, foot, flexible keel (Current Procedural Terminology (CPT) code L5972) and all lower extremity prostheses, multi-axial rotation unit ('mcp' or equal) (CPT Code L5986).

You asked the Plan to pre-approve the prosthetics. You say that the services are necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

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 prosthetics. The physician reviewer found the criteria for the all lower extremity prostheses, multi-axial rotation unit ('mcp' or equal) (L5986) and All lower extremity prostheses, foot, flexible keel (L5972) have not been met per Local Coverage Article: Lower Limb Prostheses - Policy Article (A52496). The physician documentation does not support that you meet coverage criteria for the requested items as the documentation from the physician does not support that you are at a K2 functional level. 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 prosthetics have not been met. Therefore, we decided that the Plan does not have to pre-approve all lower extremity prostheses, foot, flexible keel (Current Procedural Terminology (CPT) code L5972) and all lower extremity prostheses, multi-axial rotation unit ('mcp' or equal) (CPT Code L5986).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Medicare Part B drug injection provided on January 12, 2021.
You asked the Plan to waive the copayment for the Medicare Part B drug injection. You say that you should only have a specialist copayment. The Plan denied your request. The Plan says you were charged the copayment 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 $50 copayment for Medicare Part B prescription drugs. You have been asked to pay a $5.80 copayment for the Medicare Part B drug injection. The Medicare Part B drug injection falls within the Medicare Part B prescription drugs benefit category. The Medicare allowed amount is less than your required copayment. 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 Medicare Part B drug injection provided on January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit (99345), prolonged services (99354), and transitional care management (99495) provided on November 14, 2020 by an out of network (OON) provider.

You asked the Plan to pay for a home visit, prolonged services, and transitional care management. You say that you tried to obtain a referral for these services. The Plan denied your request. The Plan says these 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 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 a home visit (99345), prolonged services (99354), and transitional care management (99495) provided on November 14, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood transfusion services rendered on October 12, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 36430 is not supported.
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 36430 is transfusion, blood or blood components.
We find that CPT code 36430 is not supported in the medical record. Specifically, there is no report of a blood
product for these services. 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 pay for the blood transfusion
services rendered on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the out of network (OON) provider on November 11, 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 the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the out of network (OON) provider on November 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on December
17, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 70450 was not reported with an appropriate primary diagnosis code.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis
code.
We looked at the file and Medicare rules. The file shows that the claim was not billed with an appropriate
primary diagnosis code. 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 pay for the computed
tomography (CT) scan rendered on December 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0481) provided August 5, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Insufficient medical records were provided to support the billed drug testing. The plan requested additional documentation, and none was received. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0481) provided August 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on January 16,
2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 70450 is not supported.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.

The provider submitted a claim for procedure codes 70450 and 70496. Code 70450 is a column II code with a
modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the
computed tomography (CT) scan rendered on January 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upright walker.
You asked the Plan to pre-approve these services. You say that you saw a commercial for the walker and it would be easier to use. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records do not show that you are unable to use a standard walker. The requested custom/upright walker would exceed your medical needs. The services are not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an upright walker.
Local Coverage Determination (LCD) L33791 referenced by the Plan is not binding for the services at issue and was not used in the MAXIMUS determination.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve intensity modulated radiation therapy (IMRT) for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary.
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 therapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found intensity modulated radiation therapy (IMRT) is a technique used to improve the dose conformality. The use of IMRT for the treatment of breast cancer is becoming a standard approach. In general, IMRT is not an experimental technique, but rather a radiation planning and delivery tool available to the radiation oncologist to better shape the radiation dose distribution, and therefore minimize the dose to normal structures. It is noteworthy that this enrollee's BMI is around 37.5; a high BMI (clinically obese with BMI more than 30 kg/m2), is a plausible rationale for a benefit of IMRT and could be considered an exceptional circumstance. IMRT can be considered medically necessary when a clinically meaningful reduction in normal tissue dose exposure can be achieved. 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 therapy have been met. Therefore, we decided that the Plan has to pre-approve intensity modulated radiation therapy (IMRT) for the enrollee.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the removal of an odontogenic cyst (D7451), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223 x 3), and the therapeutic parenteral drug (D9610) provided on October 13, 2020.
You asked the Plan to pay for the dental services. You say that you were told this would be covered if it had nothing to do with your teeth. You say that you were seen by a dental provider because you did not want to be exposed to Covid-19 at the hospital. You also say that you went because you needed to have the exam done as soon as possible. The Plan denied your request. The Plan says the services you received are dental in nature. The Plan says that dental services are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the removal of an odontogenic cyst (D7451), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223 x 3), and the therapeutic parenteral drug (D9610) provided on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower extremity orthosis (L2999) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says CPT L2999 has been denied.
The Plan must follow Medicare rules. Medicare rules say that concentric adjustable torsion style mechanisms used to assist ankle joint plantarflexion or dorsiflexion are covered in the absence of any co-existing joint contracture. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have a knee and ankle contracture, therefore the requested custom fabricated posterior beam/strut and forefoot propulsion rocker which are both coded as L2999 are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a lower extremity orthosis (L2999) for the enrollee.
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 SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you are at baseline functional status and have met goals of care.
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 your 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 continued skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) provided on December 11, 2020.
You asked the Plan to pay for a PET scan. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with an appropriate diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate diagnosis code. We looked at the file and Medicare rules. The billed diagnosis code, C55, is not listed as an appropriate code. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) provided on December 11, 2020.