Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
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 indicating medical necessity for 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 he 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 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the onabotulinumtoxina injection (J0585), chemodenervation of one extremity; 1-4 muscles (64642), and the chemodenervation of each additional extremity (64643) provided on July 6, 2021.
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the services provided.
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 covered drugs. Additionally, enrollees pay a $20 copayment for each specialist visit.
You have been asked to pay $749.60 which includes a $20 copayment for the specialist visit and the Plan allowed amount of $3,648 x 20% coinsurance=$729.60 for the Medicare Part B drugs provided. 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 cost share for the onabotulinumtoxina injection (J0585), chemodenervation of one extremity; 1-4 muscles (64642), and the chemodenervation of each additional extremity (64643) provided on July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical evaluation services provided on June 28, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the medical evaluation services. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not received for these services rendered by an OON provider.
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 medical evaluation services provided on June 28, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interlaminar/interspinous process stabilization/distraction device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the records show that this procedure works better when the pain is relieved by bending forward.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found these devices remain experimental. More research is needed to show safety and efficacy. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve an interlaminar/interspinous process stabilization/distraction device
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on December 31, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until July 2, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided on December 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not supported because research has not found it to be helpful for the enrollee's condition or for what is causing their pain.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertilfex device is experimental. More research is needed to show safety and efficacy.
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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve True Metrix glucose test strips for the enrollee.
You asked the Plan to pre-approve the strips. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a preferred brand with the plan.
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 strips. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found it is unclear from the records why the enrollee cannot use other brands of glucometers and test strips. Since there is no reason given, nor any clear rationale evident from the chart, the enrollee does not meet the criteria for a non-preferred brand. 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 strips have not been met. Therefore, we decided that the Plan does not have to pre-approve True Metrix glucose test strips for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuropsychological testing (96132) for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says the results of the other diagnostic tests are still unknown.
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 testing. Our reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer found this evaluation is being asked for based on memory loss. It is unclear how the changes in the enrollee's treatment would occur with the requested testing. He has been showing difficulty with memory, and he has a history of atrial fibrillation and possible trauma. However, his Montreal Cognitive Assessment (MoCA) shows mild dementia. Based on a review of the records provided, the enrollee does not meet the criteria for additional testing, based on the clinical history.
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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve neuropsychological testing (96132) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fillings (D2331) for teeth # 11, 24, and 25, a filling (D2332) for tooth # 25, abutment supported crown (D6058), bone replacement graft (D7953), custom abutment (D6057), initial 15 minutes of anesthesia (D9222), an additional 15 minutes of anesthesia (D9223), implant (D6011), implant placement (D6010), and extractions (D7210) for teeth # 4 and 32.
You asked the Plan to pre-approve the dental services. You say that you were under the impression that the services were covered under this plan. You say that you do not have many resources. You also say that you are on a limited income. The Plan denied your request. The Plan says the requested dental services are not covered dental services.
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 requested dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve fillings (D2331) for teeth # 11, 24, and 25, a filling (D2332) for tooth # 25, abutment supported crown (D6058), bone replacement graft (D7953), custom abutment (D6057), initial 15 minutes of anesthesia (D9222), an additional 15 minutes of anesthesia (D9223), implant (D6011), implant placement (D6010), and extractions (D7210) for teeth # 4 and 32.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and drug screening (80305) provided on March 18, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit and drug screening. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for services rendered by an OON provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit (99214) and drug screening (80305) provided on March 18, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for balance testing services (92540, 92548, 92537, 92547, 92546, 92584, 92653) provided on March 15, 2021, and billed with a diagnosis of benign paroxysmal vertigo, unspecified ear (H81.10).
You asked the Plan to pay for the balance testing services. You say that the diagnosis is correct because the balance test was ordered to determine what is causing the enrollee's complaints of vertigo. The laterality is unknown; therefore, the diagnosis is correct. The Plan denied your request. The Plan says this claim cannot be approved because the diagnosis is missing a laterality detail.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code and diagnosis. We asked our coder 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 balance tests as billed. Our reviewer says that the billing criteria for the services at issue are not met based on the documentation provided. Laterality modifiers where not reported with procedures performed. In order to facilitate claims processing and avoid denials for duplicate claims, claims which contain codes describing services performed on anatomic structures that can be distinguished as left or right require laterality modifier. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the balance tests have not been met. Therefore, we decided that the Plan does not have to pay for balance testing services (92540, 92548, 92537, 92547, 92546, 92584, 92653) provided on March 15, 2021, and billed with a diagnosis of benign paroxysmal vertigo, unspecified ear (H81.10).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care items provided on May 11, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the wound care items. You say that the services should be covered. The Plan 
denied your request. The Plan says there was no prior authorization obtained to use the out of network 
provider. 
 
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 wound care items provided on May 11, 2021 by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a kyphoplasty.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that kyphoplasty is covered when specific criteria 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no imaging in the submitted documentation to show that the enrollee's acute fracture is less than 12 weeks old. The criteria for coverage are not met; therefore, the requested kyphoplasty is not reasonable or medically necessary for the enrollee 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a kyphoplasty
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for immunizations provided to the enrollee on October 19, 2020.
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 cannot be paid as billed. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information. The Plan says that the documentation submitted shows
the enrollee received a flu vaccine as evidenced by CPT 90662, and the provider has billed CPT 90471 as the
vaccine administration code which is incorrect. Per the Medicare guidelines, the appropriate administration
code for a flu vaccine is G0008.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case the claim
cannot be paid due an error with the administration code. Medicare rules for coverage of this service have not
been met. Therefore, we decided that the Plan does not have to pay for immunizations provided to the enrollee
on October 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee has orthostatic hypotension that requires close observation by nurses. The Plan denied your request. The Plan says the stay is not medically necessary.
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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a fall, weakness, and near syncope Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for the initial hospital care (99223) provided on January 30, 2021. 
 
You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration because the 
services were urgent and emergent and eligible for payment. The Plan denied your request. The Plan says that 
the member was not inpatient status on the billed date of service. 
 
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. Specifically, the Plan's denial in this case is neither valid nor supported with 
evidence. The record indicates that the member was discharged from another hospital and admitted to the 
billing facility on January 30, 2021. The fact that the member was an outpatient in another facility on this same 
date is irrelevant to the issue of the Place of Service code for these services. There is no indicat ion that the 
member was in an observation level of care with the billing facility on January 30, 2021. It is the burden of the 
Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in 
your favor. Therefore, we decided that the Plan has to pay for the initial hospital care (99223) provided on 
January 30, 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.