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

We decided that the Plan does not have to pre-approve the acute inpatient hospital care for thyroid surgery (CPT code 60500).
You asked the Plan to pre-approve acute inpatient hospital care. You say that it is medically necessary based on secondary hyperparathyroidism of renal origin. The Plan denied your request. The Plan says the documentation pre-operatively does not meet the threshold for an intensity of services or underlying enrollee hemodynamic instability that could only be managed in an acute inpatient setting.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for an inpatient admission for the procedure. Specifically, the surgery CPT code given is no longer on the Medicare Inpatient Only List. The review indicates that the record does not show the admitting physician reasonably expects that the enrollee's necessary hospital care will span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care for thyroid surgery (CPT code 60500).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services rendered on October 27, 2020.

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 separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.

The provider submitted a claim for procedure codes 11043 (debridement, muscle and/or fascia, first 20 sq cm
or less) and 11044 (debridement, bone, first 20 sq cm or less). Code 11043 is a column II code with a modifier
indicator of 1 when billed with column I code 11044. Code 11043 was not billed with an appropriate modifier
to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the debridement
services rendered on October 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 was admitted with hypoxia due to Coronavirus pneumonia. The record indicates that the enrollee has worsening x-ray findings and increased oxygen demands. The record indicates that the enrollee is not clinically stable. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that the enrollee is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self administered drugs provided from March 25, 2021,
to March 26, 2021.

You asked the Plan to pay for the self administered drugs. You say that the enrollee should not be responsible
for the services. The Plan denied your request.

The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are
covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered
under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pay for the self administered drugs
provided from March 25, 2021, to March 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. 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 sepsis and infected wound of
left foot. 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, in 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional speech therapy visits.
You asked the Plan to pre-approve additional speech therapy visits. The Plan denied your request. The Plan says additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve additional speech therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the enrollee has had prior extensive therapy the enrollee's caregiver was trained in programming the speech generating device. Our reviewer says that the enrollee and caregiver have had ample time for instruction on a home program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional speech therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional speech therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction you had on June 25, 2021.

You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says this is not a
covered 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 covers these services when provided during a routine eye exam.

We looked at the file and the Plan's rules. The requested eye refraction was provided during a medical eye
exam. This exam was not considered to be a routine exam. Eye refractions are only covered when provided
during a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the eye
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction
you had on June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas neo-Gen series therapy with subcutaneous injection
services provided on August 7, 2020.

You asked the Plan to pay for Sanexas neo-Gen series therapy with subcutaneous injection services. You say
that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan
says these services have not been demonstrated as effective in the peer-reviewed literature for the enrollee's
condition.

The Plan must follow Medicare rules. Medicare rules say that Sanexas neo-Gen series therapy and injection
services are subject to the criteria listed in the Medicare rules section.

Regarding the billing for therapy services, the review of the file and publicly available records indicates that
the physical therapy services at issue in this case were rendered by a provider who is not licensed to provide
physical therapy in the State of Arizona.

Regarding the injection services, the multiple drug codes reported on this claim refer to a pre-filled
compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not
otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made.
Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of Sanexas neo-Gen series therapy with subcutaneous injection services have not been met.
Therefore, we decided that the Plan does not have to pay for Sanexas neo-Gen series therapy with
subcutaneous injection services provided on August 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.

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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested Intracept procedure is considered experimental in nature for the treatment of back pain, as more research is needed to support efficacy. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair on February 7, 2021.

You asked the Plan to pay for a shower chair. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a shower chair provided on February 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift chair.
You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your
request. The Plan says this is considered a convenience item.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they
are not primarily medical in nature.
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pre-approve a stair lift chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an infusion pump refill (A4220) provided on March 15, 2021.

You asked the Plan to pay for an infusion pump refill. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of P indicates bundled/excluded codes. There are no payment amounts for these services.

We looked at the file and Medicare rules. Code A4220 has a status code of P and is bundled or excluded. Based on this information, we decided that Medicare rules for coverage of an infusion pump refill have not been met. Therefore, we decided that the Plan does not have to pay for an infusion pump refill (A4220) provided on March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on June 22, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you were not advised of any changes with your dental plan the year before you went to see the dentist. You also say that you believe you should not have to pay out of pocket for these services because the change with your plan should have been explained to you. The Plan denied your request. The Plan says these services cannot be covered under your plan for being rendered by an OON provider.

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, you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on June 22, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for transcatheter arterial chemoembolization.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral out-of-network for transcatheter arterial chemoembolization.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites - one surface, anterior (D2330) provided May 4, 2021.
You asked the Plan to pay for the resin-based composite fillings. You say that your cavities are the result of previous cancer radiation treatment and the fillings should be covered. The Plan denied your request. The Plan says this service is not covered under your benefits.
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. In this case the service does not meet any criteria for medical coverage through Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based composites - one surface, anterior (D2330) provided May 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Icosapent Ethyl.

You asked the Plan to pre-approve Icosapent Ethyl. You say that this drug is medically necessary for the enrollee. The Plan denied your request. The Plan says the requested drug is not a covered 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 Icosapent Ethyl.

Benefits for Icosapent Ethyl 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgical services (17311, Q4196) provided May 27, 2021.

You asked the Plan to waive the copayment for the surgical services. You say that the copayment should be waived. The Plan denied your request. The Plan says the original coinsurance applied was incorrect and the correct copayment has been reassessed.

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 $225 copayment for outpatient surgery.

You have been asked to pay a $225 copayment for the surgical services. The surgical services falls within the outpatient surgery 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 surgical services (17311, Q4196) provided May 27, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the medical services provided on April 23, 2021.

You asked the Plan to pay for the medical services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services are not deemed medically necessary.

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. The case file submitted to Maximus was largely incomplete. No claim form was submitted to indicate what services are at issue. The documentation does not support why these services were denied. Maximus requested information from the Plan in which was responded with the same information previously received and no new information. Therefore, we decided that the Plan has to pay for the medical services provided on April 23, 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: Partially Favorable

We decided that the Plan has to pay for the visual field exam. We decided that the Plan does not have to pay for
the refraction.
You asked the Plan to pay for the refraction and visual field exam. You say that your primary doctor had you
get your eyes checked for any signs of diabetes. You say that you want to know what part of your exam is not
covered. The Plan says that the medical eye exam was paid for and the refraction and visual field exam were
denied as non-covered benefits.
We decided that the Plan has to pay for the visual field exam.
The Plan says the visual field exam is denied as a non-covered vision benefit. The visual field exam is
considered a diagnostic test. Your contract with the Plan clearly says that you pay a $0 copayment for
diagnostic procedures and tests. Therefore, we decided that the Plan has to pay for the visual field exam.
We also decided that the Plan does not have to pay for the refraction.
Medicare and the Plan do not pay for procedures performed during any eye exam to determine the refractive
state of the eyes. Therefore, we decided that the Plan does not have to pay for the refraction.
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.