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

We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this request remains experimental in cases of spinal fusion. More research is needed to show safety and efficacy of aspirate as a bone graft material.

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 pre-approve bone marrow aspiration for the enrollee.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the enrollee requires inpatient acute rehabilitation in effort to facilitate increased independence and to return home. The Plan denied your request. The Plan says that this member is unlikely to tolerate 3 hours of intensive therapy daily with at least 15 hours of intensive rehabilitation within a 7 consecutive day period based on the documentation from treating therapists.

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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness, dehydration, anemia, elevated troponin, and acute kidney injury after recent pacemaker placement. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan Hycela for the enrollee.

You asked the Plan to pre-approve Rituxan Hycela. You say that this drug is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and stated that the QIC did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Rituxan Hycela
(Rituximab and Hyaluronidase Human, Recombinant). The QIC Physician Reviewer determined that the
enrollee has received three doses of Rituxan for autoimmune hemolytic anemia. The requested Rituxan Hycela
for the last dose Rituxan is allowed as a substitution and is reasonable and necessary. Therefore, the enrollee
meets criteria for the requested drug. The Plan argues that, while there is Drugdex support for rituximab as a
non-FDA approved indication for autoimmune hemolytic anemia (AIH), there is no Compendia support for the
use of Rituxan Hycela for the treatment of AIH. Our Medical Director has concluded that the Plan is correct
that there is no compendia support for the use of Rituxan Hycela for the treatment of autoimmune hemolytic
anemia. Additionally, the FDA-approved label states under Limitations of Use, that RITUXAN HYCELA is
not indicated for the treatment of non-malignant conditions. Rituxan Hycela cannot be approved for the
treatment of autoimmune hemolytic anemia, as it is specifically excluded by the label.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Rituxan Hycela have not been met. Therefore, we decided that the Plan does not
have to pre-approve Rituxan Hycela for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on February 23, 2021.

You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. 

Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129 and L36523 to support their denial. However, LCD L36139, L36129 and L36523 are not valid for the provider's billing state of Florida. Therefore, we are unable to use LCD L36139, L36129 and L36523 to substantiate our decision. 

While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on February 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided November 1, 2020 to November 30, 2020.
You asked the Plan to waive the copayment for the SNF services. You say that even though you were not comfortable there, you stayed to finish your treatment. After you checked out, you received a bill for $2,670. You were told this is the coinsurance and feel it is not fair to charge you with such a bill. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $0 copay per day for SNF days 1-20 and $178 copay per day for SNF days 21-100. You have been asked to pay $2,760 ($178 x 15 days) for the SNF services. The SNF services falls within the Skilled nursing facility (SNF) 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. Therefore, we decided that the Plan does not have to waive the copayment for
the skilled nursing facility (SNF) services provided November 1, 2020 to November 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this procedure is helpful for treatment of the health problem.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this request is not medically needed and it is experimental for use in spinal fusion surgery. More research is needed to show safety and efficacy of bone marrow aspirate as a bone graft material. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair.
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a recliner chair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for breast ultrasound (76641) provided December 16, 2020.
You asked the Plan to waive the copayment for the diagnostic services. You say that this was your annual mammogram, and you should not have received a bill for copayment. The Plan denied your request. The Plan says the claim was processed with the correct copayment was applied per the Evidence of Coverage.
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 $40 copayment for Medicare covered x-ray and ultrasounds. You have been asked to pay $40 for the diagnostic service. The records show that you received an additional procedure during your screening mammogram. You received a mammogram, a digital breast tomosynthesis (3D mammogram) and an ultrasound of the breast. The diagnostic service 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 breast ultrasound (76641) provided December 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 22, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical record. Specifically, the records show that the testing was performed on urine specimens, not blood specimens. 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 laboratory services rendered on July 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 4, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in the home/rehab facility setting and should have been billed with POS code 32. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office services (CPT code 99214) provided on March 9, 2021, by an out-of-network provider.
You asked the Plan to pay for the office services. You say that you have been seeing this provider since 1996 and you were unaware that you had to get a referral for this provider once you switched plans. 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 99214) provided on
March 9, 2021, by an out-of-network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra heavy-duty hospital bed (E0302).
You asked the Plan to pre-approve an extra heavy-duty hospital bed. You say that you need this bed following
the surgery you received. The Plan denied your request. The Plan says the criteria for coverage of the extra
heavy-duty hospital bed have not been met.
The Plan must follow Medicare rules. Medicare rules say that an extra heavy-duty hospital bed (E0302, E0304)
will be covered if the beneficiary's weight exceeds 600 pounds
We looked at the file and Medicare rules. In this case, the record indicates that your weight does not exceed
600 pounds. Based on this information, we decided that Medicare rules for coverage of an extra heavy-duty
hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve an extra
heavy-duty hospital bed (E0302).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder elbow wrist hand orthosis (L3960, A9901) provided on September 17, 2020.
You asked the Plan to pay for a shoulder elbow wrist hand orthosis. You say that this is supported in the records. The Plan denied your request. The Plan says the submitted documentation does not include a proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. The documentation
submitted does not include an itemized invoice or delivery ticket showing the specific items delivered. The
record shows that the Plan made several attempts to obtain the necessary documentation without success.
Therefore, we decided that the Plan does not have to pay for a shoulder elbow wrist hand orthosis (L3960,
A9901) provided on September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent observation care provided on April 8, 2021 and April 9, 2021 and observation care discharge day management provided on April 10, 2021 by an out of network (OON) provider.
You asked the Plan to pay for subsequent observation care and observation care discharge day management. You say that the provider rendered services in good faith that the facility would obtain the proper referrals and authorizations. The Plan denied your request. The Plan says you did not obtain 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 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
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 subsequent observation care provided on April 8, 2021 and April
9, 2021 and observation care discharge day management provided on April 10, 2021 by an out of network
(OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $45 copayment charged for INR services provided
December 14, 2020.
You asked the Plan to waive these copayments. You say that you should only pay for the supplies to test, not an
office visit. The Plan denied your request. The Plan says this cost share was charged based on the services
billed by your provider and your Plan contract agreement. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct 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 $45 copayment for specialist physician 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 $45 copayment charged for INR services
provided on December 14, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required on tooth
#9 provided on March 5, 2021.
You asked the Plan to pay for the core buildup. You say that you had a loose filling and went to an in-network
provider to receive the crowns and core buildup. The Plan denied your request. The Plan says benefits for this
service are limited to one time per sixty-month period.
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, crowns are limited to 1 per tooth per 5
years. The record shows that you received a core buildup on tooth #9 on February 13, 2020 and your core
buildup benefit for tooth #9 has been exhausted. Therefore, we decided that the Plan does not have to pay for
the core buildup, including any pins when required on tooth #9 provided on March 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on February 28, 2021.
You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the charges because they did not entirely treat the enrollee and referred her to the emergency room. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $65 copayment for urgently needed services. The medical records show that the enrollee received urgently needed services on February 28, 2021. Therefore, the enrollee is responsible to pay the $65 copayment. The enrollee has been asked to pay a $65 copayment for urgently needed services. Urgently needed services
fall within the urgently needed services benefit category. 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 urgently needed services provided on February 28, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the pelvic ultrasound provided on
February 17, 2021 billed with code 76857-26.
You asked the Plan to pay for the ultrasound interpretation. You say that the enrollee had multiple exams done
on the same date of service, and all should be paid. The Plan denied your request. The Plan says this code is not
payable when billed with 76775 by the same provider on the same date of service unless a modifier is used.
The Plan must follow Medicare rules. Medicare rules say that when an NCCI edit exists for a code pair, only
the Column 1 code can be paid unless a clinically appropriate modifier is used.
We looked at the file and Medicare rules. Code 76857 is a Column 2 code in relation to 76775 which was
reimbursed to the same billing provider on this date of service. No NCCI modifier was used to indicate that
separate payment can be made. Based on this information, we decided that Medicare rules for coverage of the
ultrasound interpretation have not been met. Therefore, we decided that the Plan does not have to pay for the
interpretation of the pelvic ultrasound provided on February 17, 2021 billed with code 76857-26.