Persius/hicric huggingface dataset:
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 appealing this denial. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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 the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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. 

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 lab services provided on August 3, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this test is not covered for screening.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on August 6, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 drug testing services provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for fundus photography and a routine ophthalmological examination provided on November 16, 2020.

You asked the Plan to pay for the fundus photography and a routine ophthalmological examination. The Plan denied your request. The Plan says the service was rendered by a provider who does not accept the Medicare assignment. This provider has opted out of Medicare on May 31, 2018.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for fundus photography and a routine ophthalmological examination provided on November 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the iLux procedure.

You asked the Plan to pre-approve iLux. You say that your eyes are so dry that you cannot see. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this is not a covered procedure and there are other recommended treatments for your condition.

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 iLux. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have dry eye and Meibomian gland dysfunction. The provided medical records are insufficient to determine the medical necessity and reasonableness of the requested iLux procedure. Therefore, the requested service cannot be recommended at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of iLux have not been met. Therefore, we decided that the Plan does not have to pre-approve the iLux procedure.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2751) for tooth #2.

You asked the Plan to pre-approve the crown. You say that a full coverage crown is the only long-term solution in this case. The Plan denied your request. The Plan says that this service is not medically necessary.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crown when the services are medically necessary and reasonable.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the crown. Our reviewer says that the crown for tooth #2 is recommended. Our physician reviewer found the enrollee has an x-ray demonstrated fracture of the mesial lingual cusp on tooth #2. Full crown coverage is medically reasonable and necessary as defined by Medicare rules. Our reviewer also found that the elements of the coverage rule are satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to pre-approve a crown (D2751) for tooth #2.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia, 60 mg/ml syringe.
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug does not meet the guidelines for medical necessity.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found the enrollee has not tried and failed the required drug, zoledronic acid. The reviewer found there is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the request for Prolia does not meet the criteria for 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia, 60 mg/ml syringe.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 8, 2020 and billed under Claim A.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan stated that Claim A denied because the Plan had already paid for this service under another claim. The Plan states the NPI website shows that both providers are listed as diagnostic radiology specialists and both providers work within the same professional practice or group. The Plan states the correct billing of this service needed to include modifier 59 to establish a separate and distinct service was provided. 

The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met.

Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on October 8, 2020 and billed under Claim A.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received from December 28, 2020, to December 30, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered when provided 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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services you received from December 28, 2020, to December 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Home Health Aide (HHA) services.

You asked the Plan to pre-approve HHA services. You say that the enrollee needs Home Health services. The Plan denied your request. The Plan says the medical records do not indicate that skilled care is needed in the home.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 HHA services. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation does not support that the member requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The member does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are not 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 HHA services have not been met. Therefore, we decided that the Plan does not have to pre-approve Home Health Aide (HHA) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) scan of the head provided to the enrollee on August 15, 2020 and billed under Claim A.

You asked the Plan to pay for Claim A. You say that this claim should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan stated that Claim A denied because the plan had already paid for this service under another claim. The Plan states the NPI website shows that both providers are listed as diagnostic radiology specialists and both providers work within the same professional practice or group. The Plan states the correct billing of this service needed to include modifier -59 to establish a separate and distinct service was provided. 

The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met.

Therefore, we decided that the Plan does not have to pay for computed tomography (CT) scan of the head provided to the enrollee on August 15, 2020 and billed under Claim A.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral occlusive device.

You asked the Plan to pre-approve an oral occlusive device. You say that this device is medically necessary. The Plan denied your request. The Plan says this device is not covered by Medicare. 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 an oral occlusive device. The QIC Reviewer determined that the enrollee had arthritic changes of the temporomandibular joint, and a diagnosis of inflammation of the jaw muscles (interstitial myositis). The requested oral occlusive device was not for the treatment of the teeth or structures supporting the teeth, but for the treatment of a medical condition. The Plan requested a reopen and stated the argument was not medical necessity but the fact that this oral device is not covered by Medicare. The Plan stated the temporomandibular joints are clearly supporting structures of the teeth and jaw.

Our Medical Director has concluded that the Plan is correct in this case. The DME MAC for the state where the enrollee resides has issued a Policy Article (A52512) that explicitly states that "oral occlusal appliances used to treat TMJ are considered dental devices and will be denied as non-covered." While this device may be beneficial for treatment of the condition present, it is not covered by Medicare. 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 oral occlusive device have not been met. Therefore, we decided that the Plan does not have to pre-approve an oral occlusive device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on November 25, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 the services provided to the enrollee by an out-of-network provider on November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ForeseeHome monitoring system.

You asked the Plan to pre-approve the requested services. You say that the device determines a change in the enrollee's eyes. The Plan denied your request. The Plan says the clinical value of home monitoring visual field assessment has not been demonstrated.

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 requested services. Our physician reviewer found that the enrollee has Nonexudative age-related macular degeneration, left eye, intermediate dry stage. There is insufficient evidence in the medical literature to demonstrate that the ForeseeHome monitoring system positively impacts the management and outcomes of those with nonexudative age-related macular degeneration. It is at least as beneficial as existing medically appropriate alternatives. Therefore, the requested monitor is not 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a ForeseeHome monitoring system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on August 30, 2020 and billed under Claim A.

You asked the Plan to pay this claim. You say that this service should be paid by the Plan. The Plan denied your request. The Plan says Medicare billing criteria are not met. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan stated that Claim A denied because the Plan had already paid for this service under another claim. The Plan states the NPI website shows that both providers are listed as Diagnostic Radiology Specialists and both providers work within the same professional practice or group. The Plan states the correct billing of this service needed to include modifier 59 to establish a separate and distinct service was provided. 

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met.

Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on August 30, 2020 and billed under Claim A.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 17, 2020, through November 24, 2020.

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says an inpatient level of care is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found enrollee was then an 84-year-old female with metastatic ovarian cancer who presented to the ED with fatigue, constipation. Potassium was 3.0, lactic acid, 2, BUN 40. Given Zofran, fluids, Miralax, potassium, Ativan (anxiety), morphine. The enrollee was diagnosed with hypokalemia, dehydration, lactic acidosis, and debility and admitted. Subacute rehab was suggested until permanent placement needs decided as the enrollee's daughter was having difficulty managing her at home. The enrollee's symptoms and lab findings (potassium 3.0) were stable and without signs of cardiac or other consequences. She required fluids and potassium, however, no other complicated or severe acute condition required inpatient services that would be likely to cross 2 midnights prior to being stable enough for discharge to 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 17, 2020, through November 24, 2020.