Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the advance care planning services (99497) provided on June 13, 2021.  You asked the Plan to pay for the advance care planning services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the documentation does not support the services as they were coded.  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, the CPT Code Manual definition of code 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.  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 advance care planning services. Our reviewer says that the documentation does not support payment for the claim as billed. Our reviewer found the evaluation and management documentation does not include advance care and planning documentation to confirm this procedure has been performed.  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 advance care planning services have not been met. Therefore, we decided that the Plan does not have to pay for the advance care planning services (99497) provided on June 13, 2021.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Entyvio.  You asked the Plan to pre-approve Entyvio. You say that this is medically necessary. The Plan denied your request. The Plan says that the dosage and frequency requested exceeds standards.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   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 Entyvio. Our reviewer says that the requested use of Entyvio is supported. Our physician reviewer found DrugDex, a Medicare apporved compendium, states that dose optimization (frequency increase to every-4-weeks during maintenance dosing) induced or restored clinical response in a proportion of the patients. he record indicates that the enrollee has ulcerative colitis. A colonoscopy in December 2021 indicates that the disease is currently limited to the recut. The enrollee has been on Entyvio but has low drug levels.  The requested medication is not a new start.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have been met. Therefore, we decided that the Plan has to pre-approve Entyvio.   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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for  wound care services (11042) provided on September 20, 2021, and September 27, 2021.  You asked the Plan to waive the copayment for  the wound care services. You say that the services should be covered as you were only in an examination room. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $300 copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.   You have been asked to pay a $531.82 copayment for two wound care service visits, which is less than the $300 copayment per visit states in the Plan's contract. Wound care services fall within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. The Plan states that wound care services are considered surgical services and they were performed in an outpatient hospital. 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  wound care services (11042) provided on September 20, 2021, and September 27, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay from August 7, 2021, to August 28, 2021.  You asked the Plan to waive the copayment for a SNF stay. You say that you should not be responsible for the copayment because of the quality of care at the SNF. The Plan denied your request. The Plan says the proper copayment was applied.  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 $184 copayment for per day for days 21-100. With a stay from August 7, 2021, to August 28, 2021, there was a total of 22 days in the SNF. Since days 0-20 there is no copayment charge, the charged copayment of $368 ($184 copayment x 2 days) was for days 21 and 22.  You have been asked to pay a $368 copayment for a SNF stay. A SNF stay falls within the Skilled nursing facility (SNF) care 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 a skilled nursing facility (SNF) stay from August 7, 2021, to August 28, 2021.   Your complaint about your experience with this provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Tecentriq and Mvasi for the enrollee.  You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your request. The Plan says this drug regimen is not being prescribed for a medically-accepted indication.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   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 drugs. Our reviewer says that the requested drugs are not medically reasonable or necessary. Our physician reviewer found the combination of atezolizumab and bevacizumab is Food and Drug Administration approved for the treatment of unresectable or metastatic hepatocellular carcinoma in patients who have not received prior systemic therapy. The enrollee has received several prior lines of therapy including prior immunotherapy.   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 drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq and Mvasi for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Euflexxa (J7323).  You asked the Plan to pre-approve Euflexxa. You say that the enrollee has had a contradiction to Monovisc. You also say that the enrollee would like to try Euflexxa. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drugs, Orthovisc or Supartz FX.  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 Euflexxa. Our reviewer says that Euflexxa is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed Orthovisc or Supartz FX. The reviewer also found that the documentation does not support that Orthovisc or Supartz FX would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that the requested drug, Euflexxa, is not medically necessary as the step therapy criteria have not been met.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Specifically, the file does not indicate that the enrollee has tried and failed the plan's required drugs. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit services provided on March 3, 2020.  You asked the Plan to pay for the office visit services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the claim was not filed timely per Medicare guidelines.    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 office visit services was not filed until September 13, 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 office visit services provided on March 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on May 27, 2021.  You asked the Plan to pay for the ambulance service. You say that you were at your doctor's office when they called 911 for you. You say that the paramedics asked if you wanted them to take you to the hospital or your son could drive you there. You also say that you decided to have your son drive you. The Plan denied your request. The Plan says services with a status indicator of "I" is not covered.  The Plan must follow Medicare rules. Medicare rules say that procedure code A0998 - ambulance response and treatment, no transport - has a Status Code of "I", indicating that this code is not valid for Medicare purposes and is not payable.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance service have not been met. Specifically, the file procedure code in this case has a status indicator of "I". Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on May 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Mvasi and Keytruda for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the off-label use of this regimen for this condition is not medically accepted.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the requested use of these drugs is not Food and Drug Administration (FDA) approved for the enrollee's diagnosis of glioblastoma. There are no phase III trials for this request. The use of these drugs is not listed as indicated or supported in any of the compendia or major guidelines.  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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Mvasi and Keytruda for the enrollee.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Entvyio.  You asked the Plan to pre-approve Entvyio. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says that Entyvio dosed every 4 weeks is not FDA approved or Medicare compendia supported.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Entvyio. Our reviewer says that the record indicates that the enrollee has a diagnosis moderate pan-ulcerative colitis. The record indicates that the enrollee has experienced symptomatic improvement but has low drug level. Our physician reviewer found The Food and Drug Administration has stated that the requested drug is indicated for the enrollee's condition  The elements of the coverage criteria are satisfied.  The requested service is recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entvyio have been met. Therefore, we decided that the Plan has to pre-approve Entvyio.   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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT) services.  You asked the Plan to pre-approve SBRT services. You say that this radiation therapy is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that SBRT services are subject to the criteria listed 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 SBRT services. Our reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer found for this patient, there is widespread metastases. The intent of treatment is palliative, and does not seem to meet the American Society for Radiation Oncology model policy or generic indications for SBRT being able to encompass all sites of disease. Furthermore, there is no published evidence that supports SBRT for treating the cervix or uterus. The LCD criteria are not met in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SBRT services have not been met. Therefore, we decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair with accessories.  You asked the Plan to pre-approve a power wheelchair with accessories. You say that this is medically necessary for your mobility deficit. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.   The item at issue in this appeal is specifically being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair with accessories.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy (CPT code 90832) provided to the enrollee on June 1, 2021.  

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  

Provider must attempt to consult the attending or primary care physician about the services furnished and document the consent or declination date to consultations, and the date of consultations in the enrollee's medical record." There was no documentation of contact in the enrollee's record. The listing of a referring provider on the claim does not satisfy the documentation criteria. A referral form or reference to a copy of the report available to a physician does not satisfy the documentation criteria. 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 psychotherapy (CPT code 90832) provided to the enrollee on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on April 15, 2021.  You asked the Plan to pay for the dental services. You say that you did not know that your plan did not allow for a change in dentist. You say that the Summary of Dental Benefits for 2021 does not mention the limitation of this benefit plan. You also say that you only went to the dentist once in 2021 and it should be covered. The Plan denied your request. The Plan says comprehensive oral evaluation is covered once every 3 plan years. The Plan says that complete series x-ray is covered once every 3 plan years. The Plan also says that the frequency limits have been exceeded.  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 and the services are listed as covered, the frequency limit have been exceeded. The record shows that the Plan paid for a complete series x-ray that you received on February 25, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat transforaminal epidural steroid injections.
You asked the Plan to pre-approve repeat transforaminal epidural steroid injections. You say that this treatment
is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus partially approved the services requested. The Plan requested a reopen and stated that we did
not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for repeat
transforaminal epidural steroid injections. Our  Physician Reviewer determined that one level of
bilateral transforaminal epidural steroid injections would be medically necessary. The Plan argues that this
request exceeds Medicare criteria, and the provider was made aware of this. The medical records show that you
have a diagnosis of radiculopathy in the lumbar region. The medical records show there was a previous
bilateral lumbar transforaminal epidural steroid injections at L4-5, L5-S1 on May 19, 2021, with greater than
50-60% improvement. The Plan is correct in this case. The Medicare LCD L34980 states, "No more than two
transforaminal injections may be performed at a single setting (e.g., single level bilaterally or two levels
unilaterally)". In this case, the request was to repeat injections at 2 levels bilaterally. Medicare coverage criteria
are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of repeat transforaminal epidural steroid injections have not been met. Therefore,
we decided that the Plan does not have to pre-approve repeat transforaminal epidural steroid injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on September 13, 2021, to September 19, 2021.  

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were discharged too early. You say that you should not have to pay for this stay. The Plan denied your request. The Plan says the correct copayment has been applied.  

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 $298 copayment per day for days 1-7. There is a $0 copayment for additional days for inpatient hospital care/in-network/inpatient care.   

You have been asked to pay a $298 copayment per day for days 1-6 for an inpatient hospital stay. The total amount you are being asked to pay is $1,788 ($298 x 6 days = $1,788). The correct copayment has been applied to the inpatient care that was provided. An inpatient hospital stay falls within the inpatient hospital care/in-network/inpatient care 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 an inpatient hospital stay provided by a participating provider on September 13, 2021, to September 19, 2021.