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

We decided that the Plan does not have to pay forthe drug testing coded G0481 and 80307 provided on July 9, 2020.You asked the Plan to pay forthe drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes G0481 and 80307 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen wasobtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay forthe drug testing coded G0481 and 80307 provided on July 9, 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 the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 still requires acute hospital level of care services and 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 they are 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 pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for hypomagnesemia. Medical conditions are stable. There are no medical needs requiring inpatient admission. 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 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement prosthesis (the Hi-Fidelity interface socket).
You asked the Plan to pre-approve the socket. You say that this is medically necessary. The Plan denied your request. The Plan says the requested socket does not have FDA approval, and does not meet Medicare criteria as safe and effective.
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 socket. Our reviewer says that the requested socket is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is no documentation that the replacement Hi-Fidelity interface socket at issue in this case is medically reasonable and necessary. The provided records do not document a change in your condition to necessitate a new device or irreparable damage or loss of your prior device necessitating replacement. 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 socket have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement prosthesis (the Hi-Fidelity interface socket).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug.

You asked the Plan to waive the coinsurance fora Medicare Part B drug. You say that you had the same injection in the past and only paid $150.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 20% coinsurance for Medicare Part B prescription drugs. 

You received a Medicare Part B drug on September11, 2020. The total allowed amount is $1,240.00 and 20% of that is $248.04. 

You have been asked to pay the total coinsurance amount of $248.04 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs benefitcategory. 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 coinsurance fora Medicare Part B drug.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device (CPT Code 22869). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says the device is considered experimental and 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 the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spacer is experimental and efficacy. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex Superion device (CPT Code 22869).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA1 (BRCA1, DNA repair associated), BRCA2
(BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence
analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements) (CPT Code 81162).
You asked the Plan to pre-approve the special genetic test. You say that you have a history of ovarian cancer.
The Plan denied your request. The Plan says the information does not say that you have a personal history of
breast cancer and have a reason to have genetic testing. The Plan states the information sent in does not show
how these tests will help the doctors take care of you (major, peer review, published articles) beyond enhanced
screening with imaging tests of your breasts.
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 special genetic test. Our physician
reviewer found the documentation indicates that you do not have a personal history of any cancer and although
the maternal grandmother had ovarian cancer, there is not a known mutation in the family. Since the initial
request for testing, you have been found to have a breast lump and are pending diagnostic ultrasound and
mammogram. If it turns out that your workup is positive for breast cancer, you will meet criteria for BRCA
testing due to your young age (individual breast cancer diagnosis at less than 45 years of age). The review has
determined that the medical records provided do not meet the requirements listed in the LCD for Medicare
coverage.
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 special genetic test have not been met. Therefore, we decided that the Plan
does not have to pre-approve BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair
associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full
duplication/deletion analysis (ie, detection of large gene rearrangements) (CPT Code 81162).
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 the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
pulmonary embolism. 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.
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 IRF admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan does not have to pre-approve Ilumya for the enrollee.

You asked the Plan to pre-approve Ilumya. You say that this drug is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Ilumya (Tildrakizumab-asmn). The Maximus Physician Reviewer determined that the plan's required drugs are less efficient and safe compared to Ilumya. The Plan requested a reopen and argued that there is no evidence in the literature to suggest that Ilumya has any superiority to the Plan's preferred step therapy alternatives. 
The medical records show the enrollee is a 77-year-old man with a diagnosis of psoriasis vulgaris. The Plan's preferred alternatives are Remicade (Infliximab) or Inflectra (Infliximab-dyyb), and Stelara (Ustekinumab).
The Plan is correct in this case. Evidence in the medical literature supporting that Ilumya is superior to Remicade/Inflectra and Stelara is insufficient. Therefore, Medicare 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya for the enrollee.
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 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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for knee revision surgery and was discharged home. Home health services were declined. There is ongoing weakness. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. 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 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on G0483.
You asked the Plan to pay for drug testing. You say that this is a Medicare-covered service. The Plan denied
your request. The Plan says this was not billed correctly.
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 G0483 is drug test(s), definitive, utilizing (1) drug
identification methods able to identify individual drugs and distinguish between structural isomers (but not
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type,
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g.,
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drugspecific
calibration and matrix-matched quality control material (e.g., to control for instrument variations and
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or
more drug class(es), including metabolite(s) if performed.
We find that CPT code G0483 is not supported in the medical record. Specifically, the submitted medical
records do not show that 22 or more drug classes were tested. Based on this information, we decided that
Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not
have to pay for drug testing (G0483) provided on G0483.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold harmless forthe services provided to the enrollee by an out-of-network provider from December 17, 2019, to December 28, 2019.You asked the Plan to hold harmless forthe services. The Plan denied your request.The Plan says that these services are not covered.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.You were provided the services by a contract provider. The file does not show that the Plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the Plan. You received the services with the reasonable expectation that the services would be covered under your plan.Therefore, we decided that the Plan has to hold harmless forthe services provided to the enrollee by an out-of-network provider from December 17, 2019, to December 28, 2019.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 toopen the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic ultrasound of the head and neck (76536) provided on February 13, 2020.
You asked the Plan to waive the copayment for the diagnostic ultrasound. You say that this claim initially processed with a $0 copay, and was later changed to reflect an amount of $94.49. You say the original bill should remain as it is. The Plan denied your request. The Plan says there is a $100 copay for diagnostic tests.
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 $100 copay for Outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay a $100 copay for the diagnostic ultrasound. A diagnostic ultrasound falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 diagnostic ultrasound of the head and neck (76536) provided on February 13, 2020.
Your complaint about a change in the billing status of your claim is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on March 27, 2020.
You asked the Plan to waive the copayment for an emergency room visit. You say that you were only in the lobby for 20 minutes. You say that you do not agree with having this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an emergency room visit. The correct copayment has been applied. An emergency room visit falls within the emergency 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 an emergency room visit provided by a participating provider on March 27, 2020.