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

We decided that the Plan does not have to pay for the chest x-ray (71046) billed under Claim B.
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 this claim was previously paid. Maximus overturned the Plans denial administratively as the case file lacked the paid claim. The Plan requested a reopen and provided a copy of the paid claim.
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 was previously paid under Claim A. There is no indication on the second claim or Claim B, that this was a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71046) provided to the enrollee on February 4, 2021 and billed under Claim B.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography scan (71460) provided on August 3, 2021.
You asked the Plan to pay for a computed tomography scan. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71460 is a column II code to column I code 74176. 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 a computed tomography scan (71460) provided on August 3, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the member does not meet the guidelines for coverage of skilled nursing facility 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 SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet. 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, as a practical matter, can be provided at a lower level of care (ex. home, assisted living, long term 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home oxygen compressor.
You asked the Plan to pre-approve a home oxygen compressor. You say that the Plan originally only provided
you with 2 small tanks that would last one hour each. You say that this is when you requested coverage for the
home oxygen compressor. You say that, since then, you have received 3 full sized oxygen tanks and the home
oxygen compressor is no longer needed. The Plan denied your request. The Plan says the enrollee cannot have
a home oxygen compressor and portable oxygen at the same time.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that you have portable oxygen. Portable oxygen serves the same purpose as a home oxygen
compressor. Therefore, we decided that the Plan does not have to pre-approve a home oxygen compressor
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from March 27, 2020, to April 7, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says payment of DRG 871 is not supported, as a review supports DRG 180.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS
WITHOUT MV >96 HOURS WITH MCC). 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 the
services. Our reviewer says that the services at issue in this case were not supported by the medical records.
Our physician reviewer found the review indicates that the documentation supported admission for malignant
neoplasm of bronchus or lung. The documentation was inconsistent/unclear regarding a diagnosis of severe
sepsis. Even though severe sepsis was documented, supporting medical record documentation was not found
within the record. There was no documentation of sepsis throughout the hospitalization. The review has
determined that the correct DRG to use in this case was DRG 180.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital services provided to the enrollee from March 27, 2020, to April 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a flex-walk system (L5981) for the enrollee.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your
request. The Plan says a request for complete prosthetic replacements, including K3 feet, does not meet
Medicare criteria as reasonable and 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 system. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the treating medical provider's documentation does not show that the enrollee is a K3 or above level
ambulator. Furthermore, the documentation notes that the enrollee reports imbalance, and states that it is from
the prosthetic not fitting well. However, the enrollee has a history of pain/numbness in the legs present prior to
the amputation and has a history of neuropathy which can cause imbalance. The documentation does not reveal
that the enrollee's current K3 prosthetics from another vendor given in July 2019 require replacement due to
loss, damage or wear.
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 system have not been met. Therefore, we decided that the Plan does not
have to pre-approve a flex-walk system (L5981) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bevacizumab, Dexamethasone Sodium Phosphate, Diphenhydramine HCL, Ondansetron HCL and Pembrolizumab for the enrollee.
You asked the Plan to pre-approve these drugs. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that these drugs are not being prescribed for a supported medically-accepted indication.
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 these drugs. Our reviewer says that these drugs are not medically reasonable and necessary for the enrollee. Bevacizumab, Dexamethasone Sodium Phosphate, Diphenhydramine HCL, Ondansetron HCL and Pembrolizumab are not FDA-approved in combination for the enrollee's diagnosis.
The use of these drugs is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these drugs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Bevacizumab, Dexamethasone Sodium Phosphate, Diphenhydramine HCL, Ondansetron HCL and Pembrolizumab for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chiropractic office visit (99202) provided May 29, 2021.
You asked the Plan to pre-approve the chiropractic office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says this chiropractic service is non-covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve a chiropractic office visit (99202) provided May 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chemotherapy services and a ziraveb injection provided on January 3, 2021, and January 24, 2021.

You asked the Plan to waive the copayment for the chemotherapy services and ziraveb injection. You say that the services should be covered as you've had these services done previously in 2020 and was not charged nearly as much. The Plan denied your request. The Plan says the cost-sharing applied correct based on a review of your claims from 2020. The Plan also says that you were incorrectly billed a lower amount but decided not to apply a higher copayment.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B Prescription Drugs.

You have been asked to pay a 20% coinsurance for chemotherapy services (allowed amount is $586.08 x 20% = $117.2). You have also been asked to pay a 20% coinsurance for a ziraveb injection (allowed amount is $6,244.46 x 20% = $1,248.90). Your total cost-sharing is $1,366.12. Chemotherapy services and ziraveb injections fall within the Medicare Part B Prescription Drugs 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 chemotherapy services and ziraveb injections provided on January 3, 2021, and January 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for subsequent nursing facility care provided on September 11, 2020.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says the claim was not timely filed. We overturned the Plans denial. The
Plan requested a reopen and stated due to the type of contract the enrollee was a member of the IRE applied
the incorrect claim filing requirements. The Plan says that the enrollee was a member of a Medicare Medicaid
Plan. The Plan included the Medicare documentation that explains Medicare Medicaid Plan (MMP) encounter
timeliness submissions differ from Medicare Advantage submission. Encounters should be submitted 180 days
from the date of service. In this case, the claim was filed outside of the 180-day timely filing requirement.
The Plan is correct in this case. The Plan follows Medicare rules. The rules say that claims for MMP enrollees
must be filed within 180 days of the services provided. It is the responsibility of the provider of services to
determine an enrollee's appropriate insurance coverage and the rules for claim filing. Therefore, we decided
that the Plan does not have to pay for subsequent nursing facility care provided to the enrollee on September
11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories 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 there was no written order prior to delivery.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 medically reasonable or necessary. Our physician reviewer found the documentation
does not reveal if the enrollee is unable to use a manual wheelchair in the home. The documentation does not
reveal a home evaluation supporting that the requested wheelchair can fit in the primary living spaces of the
home. The physician 6/16/21 progress note did not reveal a detailed neuromuscular exam indicating that the
enrollee does not have the strength or upper extremity function to use a manual wheelchair. Additionally, the
wheelchair evaluation noted 4/5 bilateral upper extremity strength and full bilateral upper extremity range of
motion, which should be sufficient to use the manual wheelchair.
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 a power wheelchair and accessories for the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87798) provided July 21, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were performed for screening purposes and are non-covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, COVID-19 testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (87798) provided July 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural steroid injections.

You asked the Plan to pre-approve epidural steroid injections. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections should be performed in conjunction with conservative treatments and the enrollee should be part of an active rehabilitation program. 

We looked at the file and Medicare rules. In this case, the medical documentation does not support that the enrollee is part on an active rehabilitation program, home exercise program or functional restoration program. Based on this information, we decided that Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the Plan does not have to pre-approve epidural steroid injections.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the Tempus gene panel provided on March 18, 2021.
You asked the Plan to pay for the Tempus gene panel. You say that this was medically necessary testing. The Plan denied your request. The Plan says that the number of genes tested on this panel exceeds the medical need of the enrollee.
The Plan follows Medicare rules. Medicare rules say that molecular pathology procedures such as the Tempus gene panel are considered reasonable and necessary when the criteria listed in the Medicare rules section are met. 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 the Tempus gene panel. Our reviewer says that the testing provided in this case meets criteria and is medically reasonable and necessary. Our physician reviewer found review of the National Comprehensive Cancer Network (NCCN) guidelines shows that use of comprehensive gene profiling is recommended for enrollees with metastatic pancreatic cancer. As such, the testing provided is considered 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 Tempus gene panel have not been met. Therefore, we decided that the Plan has to pay for the Tempus gene panel provided on March 18, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020), trifocal lenses (V2303) and lens tint (V2745) provided on July 19, 2021.

You asked the Plan to pay for eyeglass frames, trifocal lenses and lens tint. You say that you disagree with the denial of payment reason of your new glasses. You also say that you looked back through your medical records and found that you have not had new glasses since September 30, 2015, therefore, you have not used up your allotted money. The Plan denied your request. The Plan says you have exhausted your maximum allowance of your vision benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract also says that you receive an allowance of $150 every 24 months that you can use to pay for eyewear. If the eyewear you purchase costs more than $150, you pay the difference. 

We looked at the file and the Plan's rules. The records show that you purchased eyeglasses with lenses on July 19, 2021. The total cost for your glasses were $514. The Plan applied your $150 allowance leaving a balance of $364. The EOC confirms if the eyewear you purchase costs more than your $150 allowance, you pay the difference. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames, trifocal lenses and lens tint have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020), trifocal lenses (V2303) and lens tint (V2745) provided on July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular genetic testing (81479) provided on May 14, 2021.

You asked the Plan to pay for cardiovascular genetic testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of cardiovascular genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for cardiovascular genetic testing (81479) provided on May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided July 16, 2021.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the records do not support the billed services.
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 99214 is not supported in the medical record. Specifically, the provided records do not support that the evaluation and management service was a separate service from the osteopathic manipulation service. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided July 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra 5% drops.
You asked the Plan to pre-approve Xiidra. You say that Xiidra is medically necessary. The Plan denied your request. The Plan says this type of drug is not eligible for coverage under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra 5% drops.
Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights