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

We decided that the Plan does not have to pay for outpatient hospital services provided on October 7, 2020.
You asked the Plan to pay for this service. You say that this bill should be covered by the Plan. The Plan denied your request. The Plan says because they were not the primary payer at the time of service, this claim must be submitted to your primary payer first for review. Maximus overturned the Plans denial because the Plan did not provide verification of your primary payer. The Plan requested a reopen and provided that verification.
The Plan stated that this claim denied because the Plan is the secondary insurance. The Plan must be provided with an explanation of benefits from your primary payer at the time of service. The Plan provided documentation that they have reached out to your primary payer to obtain the documentation needed.
To date, the primary payer has not responded. The Plan states once they receive the primary payers review of the claim, they will process this claim as the secondary payer.
Based on the information provided, we now find the Plan is correct in this case. The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has attempted to coordinate with your primary payer to have the information needed sent for review so the Plan can process this claim. As the secondary insurer, the Plan cannot be held responsible for this service until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic maintenance care provided from January 6, 2020 to September 21, 2020.
You asked the Plan to pay for chiropractic maintenance care. You say that this treatment was medically necessary. The Plan denied your request. The Plan says chiropractic maintenance care is not covered by Medicare. Maximus administratively overturned the Plans denial because medical records were not submitted. The Plan requested a reopen and provided the necessary records for review.
After review of the medical records, we now find the Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. Your provider indicates in the medical records that this was maintenance care which is not covered. Therefore, we decided that the Plan does not have to pay for chiropractic maintenance care provided from January 6, 2020 to September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that this provider is a cancer specialist. You say that you would like to use this provider. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 specialist services to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is needed. The Plan denied your request. The Plan says the benefit has been exhausted.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way transportation trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of SNF services after June 13, 2021.
You asked the Plan to pre-approve the continuation of SNF services. You say that you would like reconsideration because the facility will not release you as you need more care. The Plan denied your request. The Plan says your current level of function is the same as your prior level.
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 continuation of SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or skilled therapy on a daily 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 continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of SNF services after June 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bone growth stimulator (E0747).
You asked the Plan to pre-approve the bone growth stimulator. You say that please review for medical
necessity for E0747 NU, purchase item only. Please review the attached documentation to assist in your
determination. The Plan denied your request. The Plan says the records do not support that the enrollee meets
the Medicare criteria and the requested service is medically necessary.
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. Based on this information, we decided that Medicare rules for
coverage of the bone growth stimulator have not been met. Specifically, the records do not show two x-rays 90
days apart without healing. The records also do not show the enrollee was treated for the break for 90 days and
the fracture did not heal. The records show the Plan made multiple attempts to obtain additional information
from the provider without success. Therefore, we decided that the Plan does not have to pre-approve the bone
growth stimulator (E0747).
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a chronic obstruction pulmonary disease exacerbation and aspiration pneumonia. Your medical conditions are stable.
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. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Flexitouch to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve medical supplies. You say that you would like approval for these medical supplies to be provided by an out-of-network provider. The Plan denied your request. The Plan says there are in-network providers available for these services.

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 Flexitouch to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on January 21, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the proper POS code. We looked at the file and Medicare rules. The file shows that the claim was billed with Place of Service (POS) code 12 for the home setting, which is an inappropriate POS for code 99214 (office visit). 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 office visit rendered on January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (Current Procedural Terminology (CPT)
code G0483) provided to the enrollee on February 17, 2020.
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your
request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the drug testing have not been met. CPT code G0483 90 (1 Unit)
remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the
enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was
obtained in a laboratory, place of service (POS) 81; however, the submitted medical documentation and/or
claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results
submitted indicate the specimen was collected on February 17, 2020, and received by the lab on February 18,
2020. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we
decided that the Plan does not have to pay for the drug testing (Current Procedural Terminology (CPT) code
G0483) provided to the enrollee on February 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you are weak and unable to stand or sit to take a shower. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that the requested self-administered drug not covered under the medical benefit.
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 Dupixent for the enrollee.
Benefits for this 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve psychotherapy services. You say that you would like to continue to see this therapist. The Plan denied your request. The Plan says these services can be provided in-network. The Plan says that these services can be safely transitioned to an in-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 psychotherapy services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services rendered from May 18, 2020 to May 23, 2020.
You asked the Plan to waive the copayment for these services. You say that you should have no copayment for skilled nursing facility (SNF) services. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $260 copayment per day for days 1-7 for Medicare-covered hospital care.
Review of the file shows that you received five days of inpatient rehabilitation services from May 18, 2020 to May 23, 2020. You were not assessed a copayment for your date of discharge on May 23, 2020. You have been asked to pay a $260 copayment per day for these services, for a total of $1,300. These services fall within the Medicare-covered hospital 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. The file shows that you were admitted to an inpatient rehabilitation facility and
not a skilled nursing facility. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services rendered from May 18, 2020 to May 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.

You asked the Plan to pre-approve Keytruda. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Keytruda. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a previous history of adenocarcinoma of the colon and now has peritoneal carcinomatosis and distant metastases from endometrial adenocarcinoma. The Medicare approved cancer compendia do not support the use of the requested drug as prescribed in this clinical scenario. The elements of the coverage rules are not satisfied. Therefore, the enrollee does not meet criteria for the requested drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81225, 81226, 81240, 81241, 81335, 81249, 81232, 81408, 81350, 81291, 81283, 81230, 81231, and 81328) provided on June 30, 2020.
You asked the Plan to pay for genetic testing. You say that this was medically necessary. 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. If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. We find that CPT codes 81225, 81226, 81240, 81241, 81335, 81249, 81232, 81408, 81350, 81291, 81283, 81230, 81231, and 81328 are not supported in the medical record. Specifically, the record shows that these codes were used to report genes that were tested in parallel, meaning they constitute a panel and should be reported with a single code. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81225, 81226, 81240, 81241, 81335, 81249, 81232, 81408, 81350, 81291, 81283, 81230, 81231, and 81328) provided on June 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a personal emergency response system (S5161).
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy or by Medicare.
The Plan must follow Medicare rules. Medicare rules say that alert systems are not covered because they are emergency communication systems that do not serve a diagnostic or therapeutic purpose. While an alert system may be appropriate for you in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a personal emergency response system (S5161).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services (97026, 97814, 97811 and 97810) provided on September 18, 2020, through September 21, 2020.
You asked the Plan to pay for the acupuncture services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this provider is a non-covered provider type
and the records support there is no supervision provided by a physician, physician assistant or nurse practitioner/clinical nurse specialist.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the record does not indicate that these services were rendered under the supervision of a physician, physician assistant or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for acupuncture services (97026, 97814, 97811 and 97810) provided on September 18, 2020, through September 21, 2020.