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

We decided that the Plan does not have to pre-approve Febuxostat tab 80mg for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested medication is denied as a benefit exclusion.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Febuxostat tab 80mg for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve a continuous glucose monitor. You say that this device is medically necessary for your medical condition. The Plan denied your request. The Plan says medical necessity criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation is missing complete medical records. The Plan confirmed that they requested the records multiple times and received nothing. Therefore, we do not have enough information to determine if you perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
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 IRF is the best help you can get to speed up your healing process. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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 complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF.

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 pre-approve additional inpatient psychiatric treatment.

You asked the Plan to pre-approve additional inpatient psychiatric treatment. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not
medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.

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 additional inpatient psychiatric
treatment. Our reviewer says that the documentation does not support that the requested services are medically
reasonable or necessary. Our physician reviewer found the enrollee has Alzheimer dementia. The enrollee was
not exhibiting aggressive behavior, suicidal or homicidal ideation and was not experiencing audio-visual
hallucinations. The documentation support that the assessment was unchanged from the previous day
which noted the enrollee at baseline and awaiting placement. The records provided do not indicate that the
elements of active treatment are satisfied. Therefore, the enrollee does not meet criteria for inpatient 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 additional inpatient psychiatric treatment have not been met. Therefore, we
decided that the Plan does not have to pre-approve additional inpatient psychiatric treatment.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee.

You asked the Plan to pay for this service. You say that this transport should be paid due to the destination exceptions allowed due to COVID-19. The Plan denied your request. The Plan says Medicare coverage criteria for non-emergent transport were not met. Maximus agreed with the Plans decision. You requested a reopen stating this claim should be paid due to exceptions made for COVID-19. Our Medical Director looked at the case file and the reopen request. At issue is coverage for ambulance transport. Maximus determined that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. The medical records show the enrollee is a 79-year-old man who was transported by ambulance from a nursing home to a physician's office for an appointment because of weakness and wounds on his lower back. It is noted that the enrollee was unable to ambulate due to paraplegia. Vital signs were normal. The enrollee was transferred to the ambulance and was transported to the office. The enrollee was assessed, and it was determined that there was no improvement. A clean bandage was put back on. While CMS has temporarily expanded the list of allowable destinations for ambulance transports to include physician's offices, the general coverage rules for ambulance transport still apply. The documentation does not support that the another means of transport, such as a stretcher van, was contraindicated for the enrollee at the time of transport. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on the date of transport. The documentation does not support that the ambulance transport was medically reasonable and necessary for the enrollee in this case. There are not sufficient grounds for reversing the determination in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a duplex scan.

You asked the Plan to waive the copayment for the duplex scan. You say that you should not be responsible for this copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 a $55 copayment for each Medicare-covered in-network standard x-ray and ultrasound.

You have been asked to pay a $55 copayment for the duplex scan. The duplex scan 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 duplex scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telemedicine visit.

You asked the Plan to pay for the telemedicine visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are 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 did not pre-approve the
telemedicine visit. 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 a telemedicine visit.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an OON provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid.
The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.

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 physician services provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexcom G6 Receiver Device (CPT code K0554).

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 Medicare criteria were not met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. You did not meet the criteria for the requested item because you are only using insulin two (2) times per day. 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 Dexcom G6 Receiver Device (CPT code K0554).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve drugs to be provided as part of a clinical trial.

You asked the Plan to pre-approve drugs to be provided as part of a clinical trial. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a
covered benefit.

The Plan must follow Medicare rules. Medicare rules say that Experimental care is not a covered benefit
through the medical group or by the Healthcare plan. Routine costs associated with a qualifying clinical trial are
a covered benefit through the Medicare the fee-for service mechanism. This also applies to beneficiaries
enrolled in Medicare Advantage. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of drugs to be provided as part of a clinical trial have not been met.
Therefore, we decided that the Plan does not have to pre-approve drugs to be provided as part of a clinical trial.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for optometry services (92012) provided by an OON provider.

You asked the Plan to pay for the optometry services. You say that the services were medically necessary. The
Plan denied your request. The Plan says there were network providers available.

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 service
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 optometry services (92012) provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee.

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 claim was not billed with this modifier and a corrected claim has not been received.

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 the denied codes is:

CPT 88313: 

Special stain including interpretation and report

CPT 88305: 

level IV surgical pathology, gross and microscopic examination

CPT 88311: 

Decalcification procedure (List separately in addition to code for surgical pathology examination

CPT 88185: 

Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the documentation submitted was reviewed, and it does not show that criteria has been met. The TC could have been submitted separately or combined with the professional component and reported as a combined service. Therefore, services would be billed with TC modifier.

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 pay for laboratory services provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0673, E0675).

You asked the Plan to pay for the pneumatic compression device. You say that you would like this claim
reprocessed and approved for payment. The Plan denied your request. The Plan says these services are not
covered.

The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device coded as E0675
is not eligible for reimbursement. In addition, Medicare rules say that pneumatic compression device
accessories will be denied as not reasonable and necessary when the base pneumatic compression device is not
medically reasonable and necessary.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the pneumatic compression device have not been met. Therefore, we decided that the Plan does not
have to pay for the pneumatic compression device (E0673, E0675).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a clinic visit.

You asked the Plan to pay for the clinic visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are 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 did not pre-approve the clinic visit. 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 a clinic visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital observation stay.

You asked the Plan to waive the copayment for the outpatient hospital observation stay. You say that your husband was admitted overnight from the emergency room, so there should be no copayment. The Plan denied your request. The Plan says this copayment was correctly charged.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $150 copayment for outpatient observation services.

The enrollee has been asked to pay a $150 copayment for the outpatient hospital observation stay. The billing records from this stay show that the hospital considered this stay an observation stay, not an inpatient admission. The hospital billed code G0378 (hospital observation services) for this stay. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital observation stay.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound.

You asked the Plan to waive the copayment for the breast ultrasound. You say that you shouldn't have a
copayment for this service. The Plan denied your request. The Plan says you were charged this copayment
correctly. The Plan says that because the allowed amount for this ultrasound ($102.17) is less than your
copayment obligation, you are responsible for this full 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 a $155
copayment for radiological diagnostic services (including ultrasounds).

You have been asked to pay a $155 copayment for the breast ultrasound. The breast ultrasound falls within the
radiological diagnostic services 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 breast ultrasound.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy in home per diem (S9131).

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered CPT code for Medicare.

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 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 services. Our reviewer says that the requested services were not coded correctly. Our physician reviewer found the documentation submitted does not support Medicare criteria for homebound status for criterion one or two. If the documentation supported homebound status a more appropriate code should be reported.

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 pay for physical therapy in home per diem (S9131).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a dental exam (D0140), endodontic therapy (D3320), and a CT scan of the jaw (D0364).

You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says the benefit for the dental exam was exhausted. The other services are not covered under the 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 benefit was exhausted for the dental exam and the CT scan and endodontic therapy are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a dental exam (D0140), endodontic therapy (D3320), and a CT scan of the jaw (D0364).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an OON provider.

You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services can be provided by a network
provider.

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
office visits to be provided by an OON provider.