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

We decided that the Plan does not have to pre-approve a peripheral nerve stimulator.

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 peripheral nerve stimulators are covered when specific criteria are met.

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 submitted records show that you have low back pain and are requesting an auricular percutaneous stimulator. The device is not implanted. The records do not show that you have had a trial of temporarily implanted electrodes. The device is for electro-acupuncture and 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a peripheral nerve stimulator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit (99214) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that these services are medically necessary. The Plan denied your request. The Plan says there are in-network providers available to treat your medical condition.

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 the office visit (99214) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.
You asked the Plan to pre-approve the requested services. You say that the enrollee already has dramatic healing with hyperbaric oxygen therapy. The Plan denied your request. The Plan says treatment of sternal wound dehiscence is not considered a medically necessary indication.
The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is only covered under certain medical indications. 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 requested services. Our physician reviewer found that the enrollee underwent a coronary artery bypass graft (CABG) procedure. Postoperatively he suffered from a sternal wound dehiscence. The documentation does not show that the enrollee has a compromised skin graft. The records showed that he underwent a pectoralis muscle flap and has a partial sternal wound dehiscence. Treatment of sternal wound dehiscence is not considered a medically necessary indications for HBO based on the criteria. Therefore, the requested treatment 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for echocardiographs, and specialist visits provided on April 6, 2021, and April 14, 2021.

You asked the Plan to waive the copayments for echocardiographs, and specialist visits. You say that you cannot afford the charges and do not understand the multiple billing statements you received. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $10 copayment for outpatient diagnostic tests.

Your contract with the Plan also clearly says that you must pay a $45 copayment for specialist visits. 

You received echocardiographs on April 6, 2021, and April 14, 2021. Therefore, you are responsible to pay a $10 copayment per each echocardiograph. The total amount you owe for echocardiographs is: $20. 

You received specialist visits on April 6, 2021, and April 14, 2021. Therefore, you are responsible to pay a $45 copayment per each visit. The total amount you owe for specialist visits is: $90. 

The total amount you owe is: $110.

You have been asked to pay the total copayment amount of $110 for echocardiographs, and specialist visits. Echocardiographs fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. Specialist visits fall within the physician/practitioner services, including doctor's office visits 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 copayments for echocardiographs, and specialist visits provided on April 6, 2021, and April 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, chest (71046) provided June 5, 2020.
You asked the Plan to pay for the diagnostic service. You say that please review attached reports to validate medical necessity for the above-mentioned date of service. The Plan denied your request. The Plan says certain diagnostic tests which are often performed routinely prior to surgical procedures do not meet the definition of reasonable and necessary including a chest x-ray performed preoperatively, when there is no diagnosis
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 the diagnostic service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee has a history of hypercholesterolemia, NIDDM, fatty liver, breast implant, HTN, OSA-using CPAP, osteoarthritis of multiple joints, and prior cardiac catheterization. The chest x-ray was obtained pre-operatively. The review indicates that Medicare states a chest x-ray as part of a pre-operative examination, where there is an absence of signs or symptoms indicating a need for the test, is not covered under the Medicare benefit. The review has determined that the medical records provided did not meet the requirements listed in the LCD/PIM for Medicare coverage. 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 diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for the radiologic examination, chest (71046) provided June 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from October 17, 2020, through October 20, 2020 with the reported principal diagnosis A41.89, Other specified sepsis.
You asked the Plan to pay for inpatient services provided from October 17, 2020, through October 20, 2020 with the reported principal diagnosis A41.89, Other specified sepsis. The Plan denied your request. The Plan says this decision is based on the code assignment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with you billed the inpatient services provided with reported principal diagnosis A41.89, Other specified sepsis. 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 inpatient services provided with the reported principal diagnosis A41.89, Other specified sepsis. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that there was no clinical or laboratory evidence of sepsis. The enrollee was hemodynamically stable on presentation. The review has determined that the principal diagnosis A41.89, Other specified sepsis was not supported by the medical records. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient services provided from October 17, 2020, through October 20, 2020 with the reported principal diagnosis A41.89, Other specified sepsis.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapy assistant on May 6, 2020.

You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate if the services are not available from preferred providers. 
You say that the in-network benefits should be honored, and the claim should be processed for payment. The 
Plan denied your request. The Plan says the code is not appropriate for the service billed. 
 
The Plan must follow Medicare rules.  Medicare rules say that the services of an occupational therapy assistant 
(OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, 
because they do not meet the qualifications of a therapist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a 
physician assistant, and not a licensed therapist. As such, OTA services cannot be paid incident to this 
provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational 
therapy services provided by an occupational therapy assistant on May 6, 2020.
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 April 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the medical records provided support the necessity of the services in dispute. 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 April 13, 2021 by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

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 step therapy requirement is not met.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has osteopenia and had a fragility fracture. She has not tried and failed the Plan's required drug, oral bisphosphonates. The records do not show that the required drug would be contraindicated or less effective; therefore, Prolia 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for telehealth services provided to the enrollee on January 7, 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 provider billed the claim incorrectly. Maximus overturned the Plans decision. The
Plan requested a reopen and provided additional information. The Plan says that there are no payment
restrictions on distant site practitioners furnishing Medicare telehealth services from their home during the
public health emergency. However, the practitioner should report the place of service (POS) code that would
have been reported had the service been furnished in person. This will allow our systems to make appropriate
payment for services furnished via Medicare telehealth which, if not for the PHE for the COVID-19 pandemic,
would have been furnished in person, at the same rate they would have been paid if the services were furnished
in person.
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 place of service code. In this case,
an inappropriate place of service code was billed. Medicare rules for coverage of these services have not been
met. Therefore, we decided that the Plan does not have to pay for telehealth services provided to the enrollee on
January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for primary care office visits you had from March 5, 2021, through April 26, 2021.
You asked the Plan to waive the copayments for the primary care visits. You say that you cannot afford these copayments. The Plan denied your request. The Plan says you were charged these copayments 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 $10 copayment for primary care visits. You have been asked to pay a $10 copayment for the primary care visits. 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 copayments for primary care office visits you had from March 5, 2021, through April 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided on May 19, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that you do not understand why this is being denied for being out of network when the Plan paid in network on April 1, 2021. 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 individual psychotherapy services (90832) provided on May 19, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the hip arthroplasty. 
 
You asked the Plan to pre-approve the hip replacement. You say that the surgical services should be covered. 
The Plan denied your request. The Plan says the clinical information does not establish medical necessity for 
the requested procedure. 
 
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 hip replacement. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation regarding the hip pain and how it interferes with mobility 
or activities of daily living and that the member walks in obvious pain or has limited motion in the hip. No 
imaging results were received. There were no MRI and/or CT scans noted or provided. 
 
In addition, the exam provided for review does not indicate any subjective and/or objective right hip 
complaints/deficits to support pathology in need of surgical repair/correction. Detailed documentation is not 
evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care 
measures to include any medication, physical therapy and/or home exercise program, or injections. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the request for right hip replacement is not medically reasonable or 
necessary and does not meet the criteria for coverage for a right hip replacement. 
 
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 hip replacement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the hip arthroplasty.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensive outpatient psychiatric services.
You asked the Plan to pre-approve the requested services. You say that the service is medically necessary to treat the enrollee's medical condition. The Plan denied your request. The Plan says the service is not valid for Medicare purposes.
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 S9480 is Intensive outpatient psychiatric services, per diem. We find that CPT code S9480 is not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve intensive outpatient psychiatric services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH 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. 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with a Coronavirus lung infection and shortness of breath. She requires high flow oxygen and has a rising white blood cell count. The records do not show that she requires services that she is not currently receiving that would be available at the LTACH. The LTACH services are 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.