Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral exam and panoramic x-ray provided on June 2, 2021.  You asked the Plan to pay for the limited exam and panoramic x-ray. You say that you are being overcharged for services that should be covered. The Plan denied your request. The Plan says these are covered services, but you have already used the maximum benefit for these services. You received an oral exam in March 2021, and had a panoramic x-ray done in November 2019.  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, the services provided on the date of service at issue were already covered the maximum amount for the time period. Therefore, we decided that the Plan does not have to pay for the limited oral exam and panoramic x-ray provided on June 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of the head provided on August 1, 2021, billed with code 70450.  You asked the Plan to pay for the billed code 70450. You say that this is payable because multiple exams were performed on the same date of service. The Plan denied your request. The Plan says the required modifier was not used to allow separate payment.  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 the billed code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of the head provided on August 1, 2021, billed with code 70450.
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 the enrollee is too medically complex for acute rehabilitation and skilled care. You say that the enrollee needs specialized care to help become more independent, to wean off oxygen, and to get her strength back. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee's care can be provided in the current inpatient hospital.  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 the enrollee appears to be improving and should only require short-term additional acute care services that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. An LTACH transfer is not clinically advantageous to completing treatment at the current facility.  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 pre-approve endovenous ablation therapy 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 the records do not document a six week trial of conservative therapy.
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 there is documentation that the enrollee has atherosclerosis, leg pain, absent pulses, and color changes. It is not possible to attribute the enrollee's leg symptoms to his varicose veins without an assessment of arterial perfusion. Furthermore, it is not possible to confirm the appropriateness of saphenous vein ablation if the enrollee might have significant peripheral artery disease. There is no evidence that a concerted effort at conservative therapy has been made. 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 endovenous ablation therapy for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Methotrexate tablet.  You asked the Plan to pre-approve Methotrexate tablet. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Methotrexate tablet.   Benefits for Methotrexate tablet 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 waive the copayment for the inpatient hospital admission and services provided from February 12, 2021, to February 17, 2021.  You asked the Plan to waive the copayment for the inpatient care. You say that these services were medically necessary, and the enrollee cannot afford these bills. The Plan denied your request. The Plan says they have agreed to pay for the inpatient hospital care; however, the enrollee is responsible for a $650 copayment per inpatient admission as described in the contract.  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 $650 copayment for each inpatient hospital admission.   The enrollee has been asked to pay a $650 copayment for the inpatient hospital stay. 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 the inpatient hospital admission and services provided from  February 12, 2021, to February 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq for the enrollee.
You asked the Plan to pre-approve Tecentriq. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says that malignant poorly differentiated neuroendocrine tumors of the
stomach is not a medically-accepted indication for Tecentriq.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Tecentriq. Our reviewer says that
Tecentriq is not medically reasonable and necessary for the enrollee. Tecentriq is not FDA-approved for the
enrollee's diagnosis. The use of Tecentriq is not supported by one of the major drug compendia or by clinical
research that appears in an approved medical journal. At this time, Tecentriq's use is limited to 2nd line
therapy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of
Tecentriq.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have
to pre-approve Tecentriq for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the SNF services are medically necessary. The Plan denied your request. The Plan says the documentation does not support that the member requires daily skilled nursing or skilled therapy services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can be provided at 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chiropractic services coded as G8942, 98941, G8539 and G8730 provided on January 17, 2020 to February 17, 2020 by an out-of-network (OON) provider.  You asked the Plan to pay for the chiropractic services. You say that you believe these claims should be covered. You called to verify the enrollee was eligible and was assured that even though you were an out of network provider the benefits would still be the same and covered with a $20 copay. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 chiropractic services coded as G8942, 98941, G8539 and G8730 provided on January 17, 2020 to February 17, 2020 by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Partially Favorable

 We decided that the Plan has to pay for the advanced care planning. We decided that the Plan does not have to pay for the hospital discharge day management.   You asked the Plan to pay for the evaluation and management services. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  We decided that the Plan has to pay for the advanced care planning.   The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We find that the Plan did not make or forward a decision regarding the advance care planning before forwarding the case to Maximus. Therefore, we decided that the Plan has to pay for the advanced care planning.   We also decided that the Plan does not have to pay for hospital discharge day management.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for hospital discharge day management.  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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on January 18, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when specific criteria are met.  We looked at the file and Medicare rules. There is no clinical documentation in the file to support that the criteria for coverage are met. 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 January 18, 2021.
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 is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.  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 there is no documentation provided necessitating 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 she 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 effectively 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 assisted living facility visit provided on July 2, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the assisted living facility visit. You say that the provider relied on the facility to get authorization. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.  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. It is the provider's obligation to confirm the patient's insurance coverage prior to rendering services. 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 assisted living facility visit provided on July 2, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the monitored anesthesia services provided on July 14, 2021.  You asked the Plan to pay for the monitored anesthesia services. You say that these services were medically necessary and should be covered. The Plan denied your request. The Plan says that based on local coverage article (LCA) A57361, this service was not billed with a covered diagnosis.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. In other words, it is the Plan's obligation to prove why their denial of payment is correct.  The Plan has not justified its denial here.  The Plan's sole basis for denial is that you did not bill a diagnosis code that is listed as coverable under LCA A57361. It is true that this article lists coverable diagnoses and the diagnosis that you billed on this claim is not among them.  However, the Plan has erred in its application of this LCA to this case.  This LCA is from Medicare Contractor.  This contractor's policies are controlling only in certain jurisdictions.  Specifically, this cited policy is only applicable in the following states: Colorado, New Mexico, Oklahoma, Texas, Arkansas, Louisiana, Mississippi, Delaware, District of Columbia, Maryland, New Jersey, and Pennsylvania.  There is no such applicable policy for your states jurisdiction that restricts coverage of monitored anesthesia services only to those billed with certain diagnoses.  Because the Plan has put forth no other denial rationale, and this denial rationale is inapplicable, we find that the Plan's denial is not justified. Therefore, we decided that the Plan has to pay for the monitored anesthesia services provided on July 14, 2021.   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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on April 4, 2020 by an out-of-network (OON) provider.  You asked the Plan to pay for lab tests. You say that there was no in-network alternative that could offer the needed service. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and authorization was not obtained.   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 laboratory testing provided on April 4, 2020 by an out-of-network (OON) provider.