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

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says the requested procedure is
experimental/investigational.
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 Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex device is experimental. More research is needed before coverage can be
approved. 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Vertiflex procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis
(D1110) provided on October 28, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were not aware
that the provider you normally see would not be in the office on this date of service. You also say that you
would like this claim to be paid because you were not OON. The Plan denied your request. The Plan says
services performed by an OON provider are not covered because your healthcare plan does not have OON
benefits. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and
provider eligibility.
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 (D0120) and prophylaxis (D1110) provided on October 28, 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 an epidural injection provided on August 23, 2021.
You asked the Plan to pre-approve epidural. You say that this procedure is effective for decreasing pain. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the provider has not submitted records to support medical necessity.
The Plan follows Medicare rules. Medicare rules state that epidural injections may be covered under certain circumstances. 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 epidural. Our reviewer says that this service does not meet the Medicare criteria for payment. Our physician reviewer found there is no documentation to support the medical necessity of this procedure in the cervical or thoracic region. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epidural have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural injection provided on August 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood pressure monitor (A4670), provided on April 1, 2021.
You asked the Plan to pay for a blood pressure monitor. You say that the item is medically necessary. The Plan denied your request. The Plan says the member does not meet the criteria for coverage of this item.
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 pay for a blood pressure monitor. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a blood pressure monitor have not been met. Therefore, we decided that the Plan does not have to pay for a blood pressure monitor (A4670), provided on April 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for
the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the beneficiary is an 83-year-old female with
coronavirus infection, Parkinson's disease, dysphagia with feeding tube and pneumonia. In this case, there are
both identifiable skilled nursing service needs and identifiable skilled therapy service needs. However, the
beneficiary does not require skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility
setting.
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 admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 28, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 20 additional physical therapy visits.
You asked the Plan to pre-approve 20 additional physical therapy visits. You say that the enrollee has had a drastic change in status since their discharge from the skilled nursing facility. The Plan denied your request. The Plan says the remaining PT 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 20 additional physical 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 the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan without evidence of the outcome and need for ongoing skilled therapy after the initial 10 authorized sessions. The reviewer found that without evidence of ongoing need after the initial authorized therapy sessions it is not clear that the patient requires the unique skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 20 additional physical therapy visits have not been met. Specifically, the file does not indicate that the enrollee requires additional therapy beyond the 10 approved visits. Therefore, we decided that the Plan does not have to pre-approve 20 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve all of the requested epidural steroid injections (ESIs) for
the enrollee.
You asked the Plan to pre-approve this treatment. The Plan denied your request. The Plan says while one level
was approved, multiple levels could not be approved based on the Medicare coverage guidelines. Maximus
overturned a portion of the appeal in error. The Plan requested a reopen and stated the portion overturned was
the service approved by the Plan.
The Plan is correct in this case. The Plan follows Medicare rules. Medicare rules state that it is not considered
medically reasonable and necessary for more than one spinal region to be injected in the same session.
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 epidural injections. Our reviewer says
that the enrollee does not meet the Medicare criteria for additional levels of epidural steroid injections. Our
reviewer found that only one set of epidural steroid injections may be performed, and the results need to be
evaluated before repeating the injections 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 epidural injections have
not been met. Therefore, we decided that the Plan does not have to pre-approve all of the epidural steroid
injections (ESIs) requested for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the paring of a corn on the left fifth toe provided on October
18, 2021.
You asked the Plan to pay for the paring of a corn. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or
feet or have fungal nails.
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the
paring of a corn have not been met. Therefore, we decided that the Plan does not have to pay for the paring of a
corn on the left fifth toe provided on October 18, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator trial.
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the enrollee does not have a covered indication for the spinal cord stimulator.
The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator trial is 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 a spinal cord stimulator trial. Our reviewer says that a spinal cord stimulator trial is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 75-year-old man who has both upper and lower polyneuropathy. His current pain medication is only Elavil. He has tried Physical Therapy, massage, Chiropractic, heat/ ice, and non-steroidal anti-inflammatory drugs (NSAIDs). He had psychological evaluation. The request is for a spinal cord stimulator trial. He has not had any intra-thecal medication trials. The etiology of his peripheral neuropathy is not stated. The patient does not have an evidence-based indication for a spinal cord stimulator trial. He has other evidence-based options available to him. The request is not medically reasonable or 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 a spinal cord stimulator trial have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator trial.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 6, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says an appropriate modifier was not 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. In this case, we have confirmed that code 76705 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 9, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the cost sharing for INR test supplies provided on August 23, 2021.

You asked the Plan to reduce the cost sharing for INR test supplies. You say that in the past you were only
billed 20% coinsurance. The Plan denied your request. The Plan says that you have been charged the correct
cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay 20% coinsurance for medical supplies.

The Plan says you must pay a $45 copayment for INR test supplies. Based on the Plan contract, however, you
cannot be asked to pay more than 20% coinsurance for INR test supplies. That means you are only responsible
for $18.46, which is 20% of the allowed amount for the supplies ($92.30 allowed amount x 20% = $18.46).
Therefore, we decided that the Plan has to reduce the cost sharing for INR test supplies provided on August 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: 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 enrollee is unable to walk or get to a bathroom by himself. The Plan denied your request. The Plan says the enrollee does not require coordinated care between therapy disciplines.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for surgical repair of a hip fracture after a fall. He was discharged to skilled nursing. His medical problems are stable.
The enrollee does not require treatment by multiple therapies in an intensive rehabilitation therapy program. While he has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 15, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate place of service 11. According to claims history, the specimen was obtained in an Assisted Living Facility POS 13. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on August 4, 2021.
You asked the Plan to pay for code 99291. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent providing services to the enrollee. The progress note for August 4, 2021, does not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of code 99291. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been met.
Therefore, we decided that the Plan does not have to pay for the critical care services (99291) provided on August 4, 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 requested admission to an IRF 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 based on the documentation provided you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ultrasound (76705) provided on October 1, 2021.

You asked the Plan to pay for code 76705. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are 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.

In this case, we have confirmed that code 76705 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Ultrasound (76705) provided on October 1, 2021.