Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of LTACH services.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided necessitating an admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and
condition of the enrollee and able to be furnished safely and effect ively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office services (CPT code 992149) provided to the enrollee on September 9, 2020, by an out-of-network provider.
You asked the Plan to pay for the office 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 office services (CPT code 992149) provided to
the enrollee on September 9, 2020, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the prostate thermotherapy procedure provided on
July 30, 2020 by an out of network provider.
You asked the Plan to reimburse you for the prostate thermotherapy procedure. You say that the Plan should
reimburse you for the service that was not offered in-network. The Plan denied your request. The Plan says the
procedure was not emergent and not authorized.
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 reimburse you 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 reimburse you for these services.
Therefore, we decided that the Plan does not have to reimburse you for the prostate thermotherapy procedure
provided on July 30, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for an EGD provided on February 12, 2021.
You asked the Plan to waive the deductible and copayment for an EGD. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible. Your contract with the Plan also clearly says that after the $750 deductible has been met, enrollee's must pay a $295 copayment for outpatient surgery, including services provided at hospital outpatient facilities.
You received an EGD at an outpatient hospital facility on February 12, 2021. An EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay your share of the cost-sharing charges. The record shows that you had only paid $128.10 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible balance of $621.90. Now that the $750 deductible has been met, you are also responsible to pay the remaining amount of $110.80, which is less than the $295 copayment. The total amount you owe is: $732.70. The item or service you asked the Plan to waive the deductible copayment for falls within the benefit category outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time an EGD was received on February 12, 2021. Therefore, we decided that the Plan does not have to waive the deductible and copayment for an EGD provided on February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osteogenesis stimulator.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is not met.
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 stimulator. Our reviewer says that
the requested stimulator is not medically reasonable or necessary. Our physician reviewer found the diagnosis of metatarsal non-union is not established by two sets of x-rays taken 90 days apart, showing a lack of fracture healing. The criteria is not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an osteogenesis stimulator
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (CPT code 99349) provided to the enrollee on
February 23, 2021, by an out-of-network provider.
You asked the Plan to pay for the home visit. 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 home visit (CPT code 99349) provided to the
enrollee on February 23, 2021, by an out-of-network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Artacent wound treatment for the enrollee.
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied your request. The Plan says there is insufficient evidence for this treatment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the treatment. Our reviewer says that the requested treatment is not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case the record indicates that the enrollee has diabetic foot ulcer with osteomyelitis. The wound still has evidence of necrosis and arterial insufficiency with concern of persistent infection. The requested service is not medically necessary or reasonable, as defined by Medicare rules. The elements of the coverage rule are not satisfied. 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 treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve Artacent wound treatment for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. The requested Vertiflex Superion spacer is considered experimental/investigational in nature, as more research is needed to show safety and efficacy. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) provided February 17, 2021.
You asked the Plan to pay for the office visit. You say that the chiropractors office indicated Medicare does cover manual manipulation that was done at the office visit on 02/17/2021. The chiropractor is in network with the Plan. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203) provided February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the laboratory testJ (AK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, pVal617Phe (V617F) variant) (CPT code 81270), for the enrollee.
You asked the Plan to pre-approve the laboratory testing. You say that the service is necessary. The Plan denied your request. The Plan says the enrollee's doctor did not tell the Plan that the enrollee had all the findings for this test.
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 laboratory testing. Our physician reviewer found the enrollee has a history of sleep apnea with abnormal hematological laboratory findings. The provider notes state that the enrollee's persistent polycythemia could be related to sleep apnea. The enrollee has not had any BCR-ABL testing. Medicare says JAK2 V617F, gene analysis testing can be covered if another genetic test, BCR-ABL gene analysis, is done first and the test result is negative. The file does not show that the enrollee has had a BCR-ABL gene analysis with a negative result. Therefore, based on the provided documentation, this enrollee does not effectively meet criteria for the JAK2 V617F mutation testing at this time. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pre-approve the laboratory testJ (AK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, pVal617Phe (V617F) variant) (CPT code 81270), for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the chest for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no documentation of a response to conservative management.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee has chest pain that is worse with inspiration and point tenderness in the mid-axillary line. He also has abdominal pain and flank tenderness. The CT scan will not only give the optimal view of the lungs and pleura, but also the ribs and thoracic spine. The test will be efficient and possible at the same sitting as the approved CT scan of the abdomen and pelvis. 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 scan have been met. Therefore, we decided that the Plan has to pre-approve CT scan of the chest for the enrollee.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76882) provided March 9, 2021.
You asked the Plan to pay for the ultrasound. You say that the service was medically necessary. The Plan
denied your request. The Plan says this code shares a bundled relationship with another code billed and is not
separately payable.
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 76882
has a Column I / Column II relationship with code 93971 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 an ultrasound (76882) provided March 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Opdivo injection for the enrollee.
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 is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the Medicare approved cancer compendia do not contain a supportive citation, as defined by Medicare rules, for the requested use. The enrollee is not a candidate for chemotherapy and has poor performance status. The record indicates that the enrollee has T1c, N2, Mx small cell lung carcinoma. The record indicates that the enrollee has received chemotherapy and had recurrence within six months as Stage IIIa. The enrollee has had progression of disease with brain metastases. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an Opdivo injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments charged for specialist services provided from
January 16, 2020, to January 19, 2021.
You asked the Plan to waive these copayments. You say that you do not believe these copayments are correct.
The Plan denied your request. The Plan says these copayments were charged based on the services rendered
and the claims submitted by your provider. Maximus partially overturned the Plans denial. The Plan requested
a reopen stating Maximus applied the incorrect contract language.
The Plan is correct in this case. 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 $45 copayment for specialist services.
When you send in your results or specimen or information to be reviewed, it requires a professional service to
process this information for you. Your provider has submitted a claim for these services. Therefore, a
copayment for each service applies. 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 copayments charged for specialist services
provided from January 16, 2020, to January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 12, 2021 by an out of network provider.
You asked the Plan to pay for the office visit. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the services were not urgent or emergent nor 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 service 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 the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 12, 2021 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Advair inhaler.
You asked the Plan to pre-approve an Advair inhaler. You say that your doctor believes that this medication will work for you. The Plan denied your request. The Plan says coverage of this medication is the responsibility of your prescription drug plan.
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 an Advair inhaler.
Benefits for an Advair inhaler 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: 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 you are very motivated and feel a skilled nursing
facility will not give you the appropriate amount of care. The Plan denied your request. The Plan says you can
be treated at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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 records provided, you do not require treatment by multiple therapies and
an intensive rehabilitation therapy program.
While you do require physical and occupational therapy, there is no documented need for an intensive
rehabilitation program. Medically necessary services can be provided in a lower 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.