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

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for you. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you have no identifiable skilled nursing service needs. You do have identifiable skilled therapy service needs. However, you do not require skilled nursing or therapy services on a daily basis. As a practical matter, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional six (6) ST visits.You asked the Plan to pre-approve an additional six (6) ST visits. The Plan denied your request. The Plan says an additional six (6) sessions are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 an additional six (6) ST visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. Based on the available records the enrollee appears to have plateaued with therapy and is at her baseline. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status.There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an additional six (6)ST visits have not been met.Therefore, we decided that the Plan does not have to pre-approve an additional six (6) ST visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility visits provided by an out-of-network provider from December 2, 2020 through December 30, 2020.
You asked the Plan to pay for the nursing facility visits. You say that authorization for the facility should cover any services rendered to the patient while they are in the facility. You say that the services were provided in good faith by the provider and the claims should be processed for payment. The Plan denied your request. The Plan says the doctor is out-of-network.
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 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 nursing facility visits provided by an out-of-network provider from December 2, 2020 through December 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services (88305) provided February 6, 2020.
You asked the Plan to pay for the pathology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the CPT code 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. We find that CPT code 88305 is not supported in the medical record. Specifically, CMS requires that surgical pathology, including gross and microscopic examination, of any and all submitted prostate needle biopsy specimens from a single patient be reported with one unit of service of HCPCS code G0416. Based on this information, we decided that Medicare rules for coverage of the pathology services have not been met. Therefore, we decided that the Plan does not have to pay for pathology services (88305) provided February 6, 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 these services are medically necessary. The Plan
denied your request. The Plan says that you are able to get the necessary rehabilitation, such as physical
therapy and occupational therapy at the skilled nursing 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. 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 have a past medical history of hypertension,
diabetes, neuropathy, osteoarthritis and is living at home with increasing weakness and frequent falls. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on September 4, 2020.
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 rendered 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 Texas. 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 September 4, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the additional 36 units of code 14302 billed to represent additional square centimeters of adjacent tissue transfer/rearrangement provided during a surgical procedure on December 9, 2019.You asked the Plan to pay for the additional 36 units of code 14302. You say that this was correctly billed and is allowed as the MUE for code 14302 has an MAI of 3. The operative report documents that 1353 square centimeters of tissue were transferred and rearranged with is correctly billed with a total of 44 units of this code.The Plan denied your request. The Plan says that the claim was denied as the MUE for code 14302 is 8. All units above 8 are not payable. Your appeal was denied because you did not submit the request until more than 60 days after the claim was processed.The Plan must follow Medicare rules. Medicare rules say that MUE values with an MAI of 3 may be bypassed when the records support that the excess units were actually provided. The operative report clearly documents that 1353 square centimeters of tissue was transferred. This would be expressed using one unit of 14301 and 44 units of 14302. While this may be medically unlikely based on the MUE, there is no indication that this was not actually provided in this case. As such, this edit should be bypassed and payment made for the services as billed.Therefore, we decided that the Plan has to pay for the additional 36 units of code 14302 billed to represent additional square centimeters of adjacent tissue transfer/rearrangement provided during a surgical procedure on December 9, 2019.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110) provided August 3, 2020.You asked the Plan to pay for the therapy services. You say that the services were medically necessary.The Plan denied your request. The Plan says the documentation does not support the services 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.We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows that the services were provided in the home setting. There is a more appropriate CPT code for this service (G0157). Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met.Therefore, we decided that the Plan does not have to pay for therapy services (97110) provided August 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bariatric surgery for the enrollee.

You asked the Plan to pre-approve bariatric surgery for the enrollee. You say that the requested surgery is medically necessary for the enrollee. The Plan denied your request. The Plan says the Medicare coverage criteria are not met.

The Plan must follow Medicare rules. Medicare has both a National and Local Coverage Determination for this type of surgery. Coverage is based on meeting the criteria for the Local Coverage Determination (LCD) L35022. 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 this surgery. Our reviewer says that the Medicare LCD coverage criteria are not met. Our physician reviewer found the local coverage determination states that Hepatic disease with prior documented inflammation, portal hypertension or ascites is a contraindication to surgery. The medical record indicates that he has steatohepatitis with portal hypertension and small varices. The hepatology note has deferred clearance pending further work up and evaluation in August 2021. The elements of the coverage determination are not satisfied at this time; therefore, the requested service cannot be recommended as Medicare criteria are 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 this surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the requested bariatric surgery for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services provided on February 22, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not supported.The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The submitted documentation does not contain medical records from the non-contract provider for the date of service in question. Without records, it cannot be determined that Medicare coverage criteria have been met.Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for the critical care services provided on February 22, 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 the enrollee's 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 the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
It is not clear the enrollee 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer device.
You asked the Plan to pre-approve the Superion interspinous spacer device. The Plan denied your request. The Plan says this is 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 the Superion interspinous spacer device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Superion spacer is experimental. More research is needed to show safety and efficacy of the device. 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 Superion interspinous spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81407, 81408, 81439) provided October 19, 2020.You asked the Plan to pay for the genetic testing. You say that the services were medically necessary.The Plan denied your request. The Plan says this is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.We looked at the file and Medicare rules. The documentation shows the service at issue was a cardiovascular risk assessment panel. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met.Therefore, we decided that the Plan does not have to pay for genetic testing (81407, 81408, 81439) provided October 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient hospital care after January 31, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria for inpatient care were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for continued inpatient care. Maximus determined that the record does not show that the physician responsible for the enrollee's inpatient care concurs with this discharge. The Plan argues that the records show as of February 1, 2021, the enrollee was hemodynamically stable, pain free, taking only oral medications, no longer on oxygen and deferred further treatment.

The enrollee was no longer receiving active treatment. The enrollee was at the time a 94-year-old man with a past medical history of valvular heart disease, stroke, and chronic kidney disease, who was admitted to the hospital on January 24, 2021 with heart failure. The Plan determined that the enrollee's last covered day at the acute inpatient level of care was January 31, 2021 and that care after that point was not medical in nature. The social worker was inquiring for placement as the enrollee required around the clock care.

Our Medical Director has concluded that the Plan is correct in this case. The documentation does not support that continued inpatient case was medically reasonable and necessary beyond January 31, 2021. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for acute inpatient hospital care after January 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a cholecystectomy (47600) provided on January 26, 2021.
You asked the Plan to pay for a cholecystectomy. You say that this was provided in an appropriate place of service. The Plan denied your request. The Plan says this was not billed with the correct place of service.
The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital place of service (POS) code 21 irrespective of the setting where the patient actually receives the face-to-face encounter.
We looked at the file and Medicare rules. The record shows that the enrollee was an inpatient at the time of service, but this service was reported with POS 22 for outpatient hospital. Based on this information, we decided that Medicare rules for coverage of a cholecystectomy have not been met. Therefore, we decided that the Plan does not have to pay for a cholecystectomy (47600) provided on January 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that SNF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the reopen request and the case file. At issue is coverage for SNF services. The Maximus Physician Reviewer determined that the requested SNF coverage is medically reasonable and necessary. The Plan argues that you had met your home exercise goal. The medical records show that you underwent revision of a right total hip arthroplasty on March 24, 2021, with liner and head exchange. On March 26, 2021, the records show you were able to ambulate 40 feet x 2 with minimum assistance. Your gait was reported to be smooth with no loss of balance. Our Medical Director has concluded that the Plan is correct in this case. The documentation does not support that you required skilled services on a daily basis in a skilled nursing facility after the date in question. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the PCR testing provided on February 4, 2021.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. 

We looked at the file and Medicare rules. Per LCD L37348, the requested PCR testing is not covered. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the PCR testing provided on February 4, 2021.