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

We decided that the Plan does not have to pre-approve a pontic (D6240) for teeth #4 and #5 and a retainer crown (D6750) for teeth #3 and #6.
You asked the Plan to pre-approve the dental services. You say that these services are necessary and recommended by your dental provider. The Plan denied your request. The Plan says these services are not medically necessary and are beyond the scope of what the Plan covers for these services. The Plan says that bridges are covered to replace only 1 upper anterior tooth or 2 adjacent lower anterior teeth. There cannot be any missing posterior teeth in the arch. The Plan suggests a partial upper denture (D5211) may be a functional alternative that could be considered for review.
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. The Plan covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that these services are not medically necessary. Our physician reviewer found the documentation does not support the coverage criteria for a posterior fixed bridge. Only anterior fixed bridges are considered for coverage unless there is a documented reason that a removable prosthesis cannot be used. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6240) for teeth #4 and #5 and a retainer crown (D6750) for teeth #3 and #6.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in-network rate for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), the periapical x-ray (D0220), and the unspecified preventive service (D1999) provided on November 19, 2020.

You asked the Plan to pay the in-network rate for the periapical x-ray and unspecified preventive service. You say that this dentist has always been a participating dentist. You also say that you were never informed that the dentist's participating status had changed 3 days prior to the services being performed.The Plan denied your request. The Plan says periapical x-ray is not listed as a covered service. The Plan also says that unspecified preventive service is not listed as a covered service either.

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 dental services you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay the in-network rate for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), the periapical x-ray (D0220), and the unspecified preventive service (D1999) provided on November 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) and the chronic care management services (99490) rendered by the out of network (OON) provider on December 11, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) and the chronic care management services (99490) rendered by the out of network (OON) provider on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care provided on December 15, 2020.
You asked the Plan to pay for the observation care. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that the billed services were provided on December 15, 2020. The medical records provided were for services provided on December 14, 2020. We are unable to determine if Medicare payment criteria have been met as we are unable to verify the services were provided on the billed date of service. Therefore, we decided that the Plan does not have to pay for the observation care provided on December 15, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve an injection of octreotide.
You asked the Plan to pre-approve octreotide. You say that you are appealing this denial. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the requested use of octreotide is experimental/investigational.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 octreotide. Our reviewer says that the enrollee meets the Medicare criteria for octreotide. Our physician reviewer found the requested use of octreotide is not FDA-approved for the enrollee's diagnosis. However, this use is supported by major drug compendia or by clinical research that appears in a Medicare-approved medical journal. The documentation supports that the requested drug is safe and effective, and otherwise reasonable and necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of octreotide have been met. Therefore, we decided that the Plan has to pre-approve an injection of octreotide.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laminectomy, facetectomy, and foraminotomy surgery.
You asked the Plan to pre-approve spine surgery. You say that the enrollee has progressively worsening pain and has gone through all reasonable conservative therapy for his condition. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no nerve compression documented.
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 spine surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not include Magnetic Resonance Imaging (MRI) within the last 6 months showing nerve root compression, and there is no documentation of pain scores of severe dysfunction on a physical scale. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spine surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve laminectomy, facetectomy, and foraminotomy surgery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 12, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting.Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for FoundationOne Heme testing (81455) provided on November 3, 2020.

You asked the Plan to pay for the FoundationOne Heme testing. You say that this testing was validated by the Centers for Medicare and Medicaid Service and cannot be denied by a Medicare Advantage plan. You provide reference to an LCD L38047 as evidence of coverage.The Plan denied your request. The Plan says there are numerous Medicare coverage rules which indicate that this type of panel must be billed with code 81479 along with the DEX Z-code. As such, this was incorrectly coded and cannot be paid.

Maximus reviewed the regulations cited by both the lab and the Plan. We find that these regulations do not apply either to the State in which this testing was performed or for the specific type of testing at issue. As such, our review is based on the regulations noted in the Medicare Rules section.

The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to support the medical necessity of Genomic Sequential Analyses panels for patients with CML for a limited number of individual biomarkers. Panels which test the covered biomarkers and are described by code 81450 may be covered by Medicare. 

We looked at the file and Medicare rules. Review of the information in the file shows that this panel includes analysis of over 50 genes. The billed code 81455 is defined as targeted genomic sequencing with analysis for 51 or more genes. Although some of these genes may be considered medically necessary based on the rules, the entire panel exceeds what is covered under these provisions. 

Based on this information, we decided that Medicare rules for coverage of the FoundationOne Heme testing have not been met.Therefore, we decided that the Plan does not have to pay for FoundationOne Heme testing (81455) provided on November 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta (J3304).

You asked the Plan to pre-approve Zilretta. You say that this is medically necessary. The Plan denied your request. The Plan says this is only approved for a one-time use.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Zilretta. Our reviewer says that the criteria for coverage of Zilretta have not been met. Our physician reviewer found this request is an off-label use of the Zilretta since it approved for only a single use. Therefore, the requested use is considered not medically reasonable or 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta (J3304).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on November 5, 2019.
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an office visit provided on November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0482) provided on October 7,
2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation submitted indicates that
the specimen was collected in an office setting.
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used
to reflect the actual setting where the beneficiary receives the face to-face service.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the drug testing services have not been met. Specifically, this claim was billed with a laboratory
place of service code while the record indicates that the member's face-to-face service took place in an office
setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0482) provided
on October 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan described by code 70450 provided on October 30, 2020.
You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
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, we have confirmed that code 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the CT scan described by code 70450 provided on October 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you need this service because you are unable to provide for yourself and do not have help at home. The Plan denied your request. The Plan says the SNF services you are requesting do not meet the requirements for approval.
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 the SNF admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that requires the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that requires the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the SNF admission have not been met. Although you have skilled therapy needs, these needs are not on a daily basis. Therefore, we decided that the Plan does not have to pre-approve a SNF admission.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from December 7, 2019 to January 28, 2020.
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare guidelines say that ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, followed by the manifestation. In this case, F02.80 is a manifestation code and cannot be used as the primary or first-listed diagnosis code on the claim. Based on
this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from December 7, 2019 to January 28, 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 the IRF admission is medically necessary.The Plan denied your request. The Plan says your needs can be met at a different 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. Our physician reviewer found based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the medical records provided It is not clear you would be able to fully benefit and/or participate in an IRF level of 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jardiance tablets.
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug coverage.
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 Jardiance tablets.
Benefits for self-administered drug 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve biologic materials to aid in tissue regeneration (D3431), guided tissue regeneration (D4266), several surgical placements of implant bodies (D6010) and a bone replacement graft (D7953).
You asked the Plan to pre-approve the dental services. You say that these services are necessary and costly. The Plan denied your request. The Plan says these services are not covered by the Plan or by the Plan's supplemental dental benefit.
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 biologic materials to aid in tissue regeneration (D3431), guided tissue regeneration (D4266), several surgical placements of implant bodies (D6010) and a bone replacement graft (D7953).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing provided on November 25, 2020.
You asked the Plan to pay for the ConfirmMDx testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare only covers ConfirmMDx for males who have undergone a previous cancer-negative prostate biopsy. The file shows that this was the enrollee's first biopsy. Based on this information, we decided that Medicare rules for coverage of the ConfirmMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing provided on November 25, 2020.