Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alignable system (L5910), a prosthetic cover (L5962), and a vacuum System (L5781)
You asked the Plan to pre-approve the wheelchair components. You say that the parts are necessary. The Plan denied your request. The Plan says they will overturn part of your request for a replacement socket, but not the alignable system, prosthetic cover, and vacuum system.
The Plan must follow Medicare rules. Medicare rules say that medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record. The notes do not show why member's current alignable system cannot be used with the approved replacement socket. The enrollee's physician or therapist do not document medical need for vacuum volume management system. The records provided do not indicate that the member is exposed to harsh conditions or engages in extraordinary activities that require extra protection from a specialized prosthetic cover, L5962. This cannot be covered per Medicare rules as standard prosthetic covers have already been approved and is sufficient for everyday use. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wheelchair components have not been met. Therefore, we decided that the Plan does not have to pre-approve an alignable system (L5910), a prosthetic cover (L5962), and a vacuum System (L5781).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the breath hydrogen or methane test (91065).

You asked the Plan to pre-approve the breath hydrogen or methane test. You say that you were diagnosed with SIBO and was given a prescription for antibiotics. It is important that you find out if the drug is necessary and the only way you can be sure is to take the SIBO breath test. The Plan denied your request. The Plan says this test is not indicated to diagnose SIBO.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at this physician's revie the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the breath hydrogen or methane test have not been met. Therefore, we decided that the Plan does not have to pre-approve the breath hydrogen or methane test (91065).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical care with an out of network (OON) provider.
You asked the Plan to pre-approve the OON surgical care. You say that the enrollee has multiple severe
problems with small bowel obstructions and needs surgery again that should be done with the expertise of the
surgeon who had corrected the problem in the past. The Plan denied your request. The Plan says the clinical
information does not indicate that the services required are unavailable from plan providers.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few
exceptions, enrollees must use contract providers for care. 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 OON surgical care. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found the record indicates that the enrollee has a complex ovarian mass. The record indicates that the enrollee has had previous gastrointestinal surgeries. The record does not indicate that in network providers are not available or inadequate to manage the enrollee's condition. The provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's condition. 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 OON surgical care have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical care with an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 testing provided on May 10, 2021, billed with Healthcare Common Procedure Coding System (HCPCS) code U0002.
You asked the Plan to pay for the COVID testing as billed. You say that these codes described different services, and all other payors, including Medicare, have paid for both codes when billed. The Plan denied your request. The Plan says the use of two codes to report a single COVID test is not supported.
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.
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 COVID testing as billed. Our reviewer says that the use of two codes to report this single COVID test is not supported. Our reviewer found review of the claim shows that payment was made for CPT code 87635, and HCPCS code U0002 was denied. The use of CPT versus HCPCS codes is dependent on the payor. If the claim is submitted to a payer that requires CPT codes, then code 87635 should be reported. Conversely, if the payer requires use of the HCPCS code, the HCPCS code should be reported. CPT and HCPCS codes for the same procedural services should not both be reported on the same claim. 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 COVID testing as billed have not been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 testing provided on May 10, 2021, billed with Healthcare Common Procedure Coding System (HCPCS) code U0002.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the cardiovascular monitoring services (93329).
You asked the Plan to pre-approve the cardiovascular monitoring services. You say that you are requesting an appeal of the plan's denial. The Plan denied your request. The Plan says that the requested service is not 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. In this case specific records or information was required to substantiate the plans denial. Only 3 pages which consisted of the reconsideration background data form (RBDF) was received from the Plan. The case file which includes a case summary, the Plan's initial denial, the provider's appeal, the Plan's reconsideration determination and the medical records were required. A request for the missing case file was sent to the health plan on October 4, 2021 with a due date of October 7, 2021. As of the date of this letter, the plan has not responded to our request and/or submitted the required information. Therefore, we decided that the Plan has to pre-approve the cardiovascular monitoring services (93329).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on January 22, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the nursing facility care. You say that the medical records provided support the necessity for your provider to render services. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on January 22, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zarxio.
You asked the Plan to pre-approve Zarxio. You say that this drug is medically reasonable. The Plan denied your request. The Plan says the criteria for coverage have not been met.
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 Zarxio. Our reviewer says that the requested drug is not medically reasonable and necessary for the enrollee's condition. Our physician reviewer found secondary prophylaxis with a colony stimulating factor (CSF) is recommended for patients who experienced a neutropenic complication from a prior cycle of chemotherapy (for which primary prophylaxis was not received), in which a reduced dose or treatment delay may compromise disease-free or overall survival or treatment outcome. In many clinical situations, dose reduction or delay may be a reasonable alternative. This patient has not had neutropenic fever and neutropenia was noted in labs done 6 days prior to the next cycle of chemotherapy which may not be an accurate reflection. The use of Xarxio is 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 Zarxio have not been met. Therefore, we decided that the Plan does not have to pre-approve Zarxio.
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 you need SNF care. 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 that you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are currently ambulating more than 100 feet. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. The enrollee's care needs, as a practical matter, can be provided 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 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 to the enrollee on April 15, 2021, by an out-of-network provider.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided to the enrollee on April 15, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Methylprednisolone Acetate 40 mg injection provided March 9, 2021.
You asked the Plan to waive the cost share for the drug injection. You say that you believe these services should be covered. The Plan denied your request. The Plan says the coinsurance has processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a total cost share $31.18 for the drug injection services ($30 specialist copayment +1.18 coinsurance). This service falls within the Medicare Part B prescription drugs benefit category and
specialist services 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 cost share for the Methylprednisolone Acetate 40 mg injection provided March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings were ordered by your lymphedema specialist and you would like to appeal the denial. The Plan denied your request. The Plan says this item is not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional home health skilled nursing care visits.
You asked the Plan to pre-approve 12 additional home health skilled nursing care visits. You say that home health care is medically necessary. The Plan denied your request. The Plan says you are enrolled in hospice care and not eligible for payment for home health services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 12 additional home health skilled nursing care visits. Our reviewer says that the requested home health care is not medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. As such, the requested home health services are not shown to be currently medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 12 additional home health skilled nursing care visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional home health skilled nursing care visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF. You say that the enrollee is not at the point where he can return to assisted living. You say that the enrollee still needs two-person assist to get out of bed and out of chairs. You say that the enrollee should continue to have coverage for SNF care until he can qualify for long term care assistance. The Plan denied your request. The Plan says the enrollee is medically stable with no daily skilled care needs. The Plan says that the continuation of SNF care is not medically necessary.
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. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs can be provided 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 SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the subsequent inpatient evaluation and management (EM) services provided on November 10, 2020.
You asked the Plan to pay for the inpatient EM services. You say that the enrollee was treated by multiple providers of different specialties on this date of service. The Plan denied your request. The Plan says that both initial hospital care and subsequent hospital care codes are "per diem" services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice. Payment for this date of service was previously made to another physician.
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 Plan has indicated that payment for another inpatient EM code was made to a physician of the same specialty on the same date of service. However, the Plan failed to include any evidence of the claim, or any evidence to which physician payment was made. With the documentation available, Maximus is not able to confirm this occurred. The records submitted confirm that the patient was seen on this date of service by another provider for a nephrology (kidney) consultation. The services at issue in this case refer to a endocrinology consultation performed by a nurse practitioner. We find that denial of payment for this endocrinology consultation is not supported. Therefore, we decided that the Plan has to pay for the subsequent inpatient evaluation and management (EM) services provided on November 10, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services billed as code 99285 provided on October 31, 2020.

You asked the Plan to pay for the emergency room services. You say that the billed code is supported by the medical records. The Plan denied your request. The Plan says the medical records support a lower level of care.

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 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. 

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 emergency room services. Our reviewer says that the medical record does not support the billed code. Our reviewer found that the emergency room visit does not support a billed code of 99285. Documentation must support 3 of 3 key components when reporting emergency room evaluation and management codes. Documentation supports per 95 guidelines: History (Expanded Problem Focused - brief history of present illness; extended Review of Systems; Complete PFSH), Exam - Comprehensive (11 total organ systems reviewed); MDM - moderate complexity (moderate presenting problem; minimal procedures and minimal management options). A more appropriate code to report in this case is CPT 99283. 

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 emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room services billed as code 99285 provided on October 31, 2020.