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

 
We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. You say that Gel-One is medically necessary. The Plan denied 
your request. The Plan says a trial of Durolane, Monovisc, or Synvisc-One is required before alternatives can 
be considered. 
 
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 Gel-One. Our reviewer says that Gel-
One is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred 
drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 27, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the 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 patients medical record. There 
was no documentation of contact in the patient record. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on September 27, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (G0483) provided to the enrollee on April 27, 2022.
You asked the Plan to pay for the drug testing. You say that you have provided medical records to support the services billed. The Plan denied your request. The Plan says that rules for payment have not been met because the case record does not contain a physician order for the services at issue. Maximus overturned the Plan's denial. The Plan requested a reopening and provided documentation to show that an invalid physician order was provided.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the drug testing have been met. The physician order has not been provided for this enrollee. Therefore, we decided that the Plan does not have to pay for the drug testing (G0483) provided to the enrollee on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).
You asked the Plan to pre-approve a complete upper denture. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted.
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. Maximus overturned the Plan's denial. The Plan requested a reopening and submitted documentation confirming you have already had this service covered in the last five years.
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record shows your benefit for the requested item or service was exhausted on date of service October 4, 2021. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from January 5, 2022, to February 3, 2022.
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed with the correct admission date.
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a NOA must be submitted for the first period of care in 2022, using the first date of the period as the "admission" date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA. We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from January 5, 2022, to February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
You asked the Plan to pre-approve a complete maxillary denture. You say that you are having trouble eating with having lost so many teeth. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted.
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. Maximus overturned the Plan's denial. The Plan requested a reopening and provided documentation to show a complete maxillary denture has been provided in the last five years. Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply.
The record shows your benefit for the requested item or service was exhausted on date of service April 7, 2021. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 1, 2021, under codes 76937, 37814, 37185 and 75827.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met for code 76937. Maximus overturned the denial for code 76937. The Plan requested a reopen and provided additional information regarding the appropriate billing of this code. The Plan noted that on the physician fee schedule the "ZZZ' indication means that this code is related to another service and is always included in the global period of the other service billed. The Reimbursement Policy (CMS 1500), Add-On Codes Policy for Addon to Primary Code Relationship List; includes add-on codes which will only be reimbursed when reported with the appropriate primary code. The Plan submitted this code list. The Plan notes that as the code 76937 was billed without an appropriate primary code and not performed by the same practitioner on the same date of service, the Medicare rule for payment of code 76937 has not been met. The Plan states a corrected claim would be considered if submitted.
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 code.
In this case, code 76937 has the "ZZZ" indicator requiring that this code be billed with an appropriate primary code which was not reflected on the submitted claim. Medicare rules of this code have not been met. Therefore, we decided that the Plan does not have to pay for surgical services provided to the enrollee on October 1, 2021, under code 76937.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from February 9, 2022, through February 11, 2022.
You asked the Plan to pay for the home health services. You say that you would like this claim reprocessed and approved for payment based on the NOA having previously been submitted. The Plan denied your request. The Plan says that the Medicare rule for payment of this February 09, 2022, through February 11, 2022, claim has not been met and could not be processed for payment.
The Plan follows Medicare rules. The rules say that for home health services a NOA must be submitted for the first period of care in 2022, using the first date of the period as the "admission" date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA. We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from February 9, 2022, through February 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from June 25, 2021, to July 24, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information.
The Plan noted that the provider incorrectly billed the Federal Information Processing Standards (FIPS) number with an invalid 7-digit code. The correct code should have been 5 digits under the value code 85.
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 this claim could not be paid due to an invalid FIPS code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from June 25, 2021, to July 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria are not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the
correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for inpatient
rehabilitation facility (IRF) services. The Maximus Physician Reviewer determined that the requested IRF care
was medically reasonable and necessary. The Plan requested a reopen and stated Maximus did not apply the
correct criteria. The medical records show you were admitted to the hospital on September 15, 2022, with
multiple rib fractures and a traumatic hemopneumothorax. A chest tube was placed; this was removed on
September 16, 2022.
You were cleared for discharge on September 19, 2022. On September 23, 2022, physical therapy notes
documented a requirement for minimal contact assistance for sit-to-stand and stand-to-sit and assistance for
ambulation to 55 feet with a hemi-walker. The plan is correct in this case. The documentation does not support
that the complexity of the nursing, medical and rehabilitation needs required an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing services (81455) provided on April 11, 2022.
You asked the Plan to pay for the laboratory testing services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the specimen was collected during an outpatient encounter.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. 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 code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing services (81455) provided on April 11, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for continued skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to provide coverage for continued SNF care. You say that at the time of the appeal, continued SNF care was medically necessary for the enrollee. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial for the lack of a notice of non-coverage document in the case file. The Plan requested a reopen and provided the required document.
The Plan is correct in this case. 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. Based on the medical records provided, as of August 17, 2022, the enrollee would no longer require daily skilled nursing or daily skilled therapy services at an inpatient level of care. Medicare rules for continued coverage of SNF admission were not met. Therefore, we decided that the Plan does not have to provide coverage for continued skilled nursing facility (SNF) care for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, SNF admission was medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial for a lack of Notice of Non-Coverage documentation in the case file. The Plan requested a reopen and provided the required documentation.
The Plan is correct in this case. 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. Based on the medical records provided, at the time of the appeal, the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee also did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that at the time of the appeal, SNF admission was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria for SNF admission were not met. Maximus overturned the Plans denial for a lack of documentation of notice of non-coverage in the case file. The Plan requested a reopen and provided the required notice document.
The Plan is correct in this case. 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. Based on the medical records provided, at the time of the appeal, you did not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You also did not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. Medicare coverage criteria were 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided to the enrollee on March 22, 2022.
You asked the Plan to pay for the dental services. You say that these dental services should be covered by the Plan. The Plan denied your request. The Plan says coverage for these services was not available on the date they were rendered. Maximus partially overturned the Plans denial for a lack of claim information submitted. The Plan requested a reopen and provided additional information. The Plan provided documentation to show you received a set of x-rays (D0210) on July 21, 2021, and another set of x-rays (D0210) on March 22, 2022, which is less than 3 years after the first one.
The Plan is correct in this case. Medicare 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, certain limitations apply.
The record shows your benefit for these services was exhausted prior to the date of service in question. Therefore, we decided that the Plan does not have to pay for dental services provided on March 22, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services (88361-59, 88312-XE, and 88112) provided to the enrollee on February 21, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information regarding the denial rationale. The Plan requested a reopen and provided additional information. The Plan noted that a laboratory cannot be paid for the technical component of a physician pathology service furnished to an enrollee in a hospital outpatient setting.
The claim should have been billed with a 26 modifier to show the professional component. The provider is billing globally for both the physician and the technical component while billing a Place of Service (POS) of 22 for Outpatient Hospital since that is where the specimen was obtained. However, the Medicare guidance states a lab will not be paid for the technical component of a physician pathology service furnished to a hospital outpatient. Medicare billing criteria were not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to the omission of a required modifier. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient hospital services (88361-59, 88312-XE, and 88112) provided to the enrollee on February 21, 2022.