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

We decided that the Plan does not have to pre-approve a Synvisc injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is "buy and bill" and is usually obtained by the provider and injected in the office.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve a Synvisc injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve the total electric hospital bed. You say that the bed should be paid for as you need it for safe transfer. The Plan denied your request. The Plan says a total electric bed is not a covered item.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the panoramic x-ray (D0330) provided on October 22, 2020.

You asked the Plan to pay for the dental services. You say that you were getting an annual check up and cleaning. You also say that these services should be covered at 100% as these are covered once per year. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 years. The Plan says that the frequency limit has been exceeded. The Plan also says that panoramic x-ray is not listed as a covered service.

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 and comprehensive oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on October 20, 2018, less than 3 years ago. Additionally, panoramic x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the panoramic x-ray (D0330) provided on October 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that your spouse does not have resources or ability to care for you due to health concerns. The Plan denied your request. The Plan says the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitative 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. Our physician reviewer found the patient was admitted for syncope, left hip contusion and anemia Medical conditions 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. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient admission and stay for the enrollee.

You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says the notes did not show severe blood pressure or heartbeat problems that did not get better with treatment, very high fever, severe dehydration, seriously low oxygen level in the blood, or problems with breathing.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the records did not show that at the time of inpatient admission the admitting
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or
observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for acute inpatient admission and stay for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva for the enrollee.

You asked the Plan to pre-approve Xgeva. You say that this should be covered by the Plan. The Plan denied your request. The Plan says that Original Medicare covers routine costs associated with clinical trials.

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.

In this case, you asked the Plan to pre-approve Xgeva as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Xgeva for the enrollee.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to hold the enrollee harmless for the skilled nursing facility (SNF) services provided from January 1, 2021, through February 15, 2021.
You asked the Plan to hold the enrollee harmless for the SNF stay. You say that you do not understand why you are being billed $5959.44 for the 18 days between January 28, 2021, and February 15, 2021. You feel this should be covered as the enrollee has Covid-19 during these dates. The Plan denied your request. The Plan says that the correct cost sharing has been applied.
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 Plan failed to submit a complete case file with documentation that related to the issues brought up in your appeal statement. The enrollee appears to have been a patient at the SNF in question from at least December 29, 2020. However, no enrollee liability was applied during the time in December 2020. The file included an Explanation of Benefits which indicates that the enrollee was responsible for $1958 for SNF services provided in January 2021. Maximus requested clarification from the Plan regarding this number because it does not correspond with any number of whole-day copayments based on the contract. Furthermore, your appeal statement clearly was in regard to a bill you received from the facility for dates January 28, 2021, through February 15, 2021. The Plan failed to address this amount or these dates. The file did not contain any evidence of what days of this SNF stay were covered nor when coverage was discontinued. Based on the specific services being appealed and the lack of pertinent documentation regarding these services, we are not able to verify what the correct cost sharing would be for the services provided during this span of dates. It is the Plan's responsibility to support that the amount being assigned to cost sharing, and any denied amounts were correctly calculated, and it has not done so in this case, despite Maximus sending a request for additional information. The Plan's processing of the claims as documented in the file is not supported. Therefore, we decided that the Plan has to hold the enrollee harmless for the skilled nursing facility (SNF) services provided from January 1, 2021, through February 15, 2021.
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 pre-approve a complete denture - maxillary (D5110) and complete denture - mandibular (D5120).
You asked the Plan to pre-approve complete upper and lower dentures. You say that the dentures are medically necessary. The Plan denied your request. The Plan says dentures are not covered under your medical or dental benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) and complete denture - mandibular (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinalysis (Current Procedural Terminology (CPT) code 81002) and the office services (CPT code 99213) provided to the enrollee from October 7, 2020, through October 15, 2020, by an out-of-network provider.
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 the urinalysis (Current Procedural Terminology (CPT) code 81002) and the office services (CPT code 99213) provided to the enrollee from October 7, 2020, through October 15, 2020, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical and imaging services rendered on October 23, 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 codes 37252, 37253, 76942-59, and 36247-59 are 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 37252 is intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; initial noncoronary vessel (List separately in addition to code for primary procedure). The definition of code 37253 is intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure). The definition of code 76942 is ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation. The definition of code 36247 is selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family.
We find that CPT codes 37252, 37253, 76942, and 36247 are is not supported in the medical record. Specifically, the operative report does not contain documentation of an intravascular ultrasound of a noncoronary vessel during a diagnostic evaluation/therapeutic intervention for the initial vessel to support code 37252 or of each additional vessel to support code 37253. There is no documentation of imaging supervision and interpretation of ultrasonic guidance for needle placement to support code 76942. The operative report does not contain documentation of selective catheter placement into the arterial system to support code 36247.
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 75710 (angiography) and 37227 (endovascular revascularization). Code 75710 is a column II code with a modifier indicator of 1 when billed with column I code 37227. Code 75710 was not billed with an appropriate modifier to allow for separate payment.
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 surgical and imaging services rendered on October 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on November 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab test. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.
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 laboratory testing provided on November 17, 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 Zoster (shingles) vaccine (Current Procedural Terminology (CPT) code 90750) provided to the enrollee on October 27, 2020.
You asked the Plan to pay for the vaccine. You say that the claim should be paid. The Plan denied your request. The Plan says this is not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for Zoster (shingles) vaccine (Current Procedural Terminology (CPT) code 90750) provided to the enrollee on October 27, 2020.
Benefits for the vaccine 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care (99223) provided on January 31, 2021.
You asked the Plan to pay for the evaluation and management service. You say that the service was medically necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on January 5, 2021. The service in question was provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99223) provided on January 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered from September 23, 2020 to November 18, 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 codes 73565, L0650, and 20610 are 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. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. In this case, the CPT Code Manual definition of code 73565 is radiologic examination, knee; both knees, standing, anteroposterior. The definition of code L0650 is lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s). The definition of code 20610 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance. We find that CPT codes 73565, L0650, and 20610 are not supported in the medical record. Specifically, there is no documentation of an x-ray of both knees to support code 73565. There is no documentation of arthrocentesis to support code 20610. There is no valid physician order to allow payment of code L0650. 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 services rendered from September 23, 2020 to November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical cell stimulation and Nutri-Pharmaceutical blend injections (97150, 97016, 97032) provided June 2, 2020.
You asked the Plan to pay for the electrical cell stimulation and Nutri-Pharmaceutical blend injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the services at issue are considered experimental.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the electrical cell stimulation and Nutri-Pharmaceutical blend injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Nutri-Pharmaceutical blend injection and electrical cell stimulation (Sanexas neoGen-Series Therapy) were performed 24 times. A review of the current literature for each of these treatment categories did not reveal sufficient high-quality literature supporting their general use in the setting of diabetic neuropathy or chronic pain syndrome 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 electrical cell stimulation and Nutri-Pharmaceutical blend injections have not been met. Therefore, we decided that the Plan does not have to pay for electrical cell stimulation and Nutri-Pharmaceutical blend injections (97150, 97016, 97032) provided June 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on July 17, 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 97110 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were rendered in the home setting and there is a more appropriate code 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 physical therapy services rendered on July 17, 2020.