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

We decided that the Plan has to waive the cost sharing for the inpatient hospital services you received from December 30, 2020, to January 6, 2021.

You asked the Plan to waive the cost sharing for the inpatient hospital services. You say that you were told that you shouldn't be paying this cost sharing because your admission was related to the Coronavirus (COVID-19). The Plan denied your request. The Plan says that it is not part of the Plan's process to remove member cost sharing for inpatient hospital services due to COVID-19.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan does say that there is a $750 annual deductible and, once met, enrollees pay a $300 copayment per admission for inpatient hospital services. However, the Plan's argument that "it is not part of the Plan's process to remove member cost sharing for inpatient hospital services due to COVID-19" is simply not correct. The Plan's own website explicitly states that "Now through October 20, 2021, we are waiving all deductibles, coinsurance, and copays for in-network inpatient COVID-19 treatment for members."

We contacted the Plan to have them explain their denial rationale based on the clearly contradictory language on their website. The Plan responded by advising that you had already had an inpatient admission for COVID-19 where the cost sharing was waived. The Plan also said that because this second admission was not for the COVID-19 infection itself, this copayment waiver does not apply.

We do not find the Plan's argument persuasive. As noted above, the website language regarding this inpatient copayment waiver states that the Plan is "waiving all deductibles, coinsurance, and copays for in-network inpatient COVID-19 treatment for members." The medical records from the admission from December 30, 2020, to January 6, 2021 clearly state that this admission was for 'COVID-19-related pneumonia." There is nothing in the language from the Plan's website that indicates that the copayment waiver only applies to an initial hospitalization for the infection itself. A reasonable person would understand the language on the website to mean that any hospitalization related to the treatment of COVID-19 or its symptoms (which this second admission was based on the medical records) would be included in the waiver program. Therefore, we decided that the Plan has to waive the cost sharing for the inpatient hospital services you received from December 30, 2020, to January 6, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that ventilators (E0465, E0466, and E0467) are covered for specific conditions. 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 portable ventilator. Our reviewer says that the item is not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. There is no evidence that BiPAP has been tried and failed in the home setting while stable. 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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Visolux digital electronic HHM (V2600).

You asked the Plan to pre-approve Visolux digital electronic HHM. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that low vision aids (V2600, V2610, V2615) will be denied as noncovered because coverage under the Medicare prosthetic benefit is limited to persons with congenital absence or surgical removal of the lens of the eye. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Visolux digital electronic HHM have not been met. Therefore, we decided that the Plan does not have to pre-approve Visolux digital electronic HHM (V2600).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional computed tomography (CT) scan (71275) provided on May 6, 2021.

You asked the Plan to pay for an additional CT scan. You say that this is not a duplicate. The Plan denied your request. The Plan says the supported unit was previously billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 

We find that an additional unit of CPT code 71275 is not supported in the medical record. The medical record only supports 1 unit of CPT code 71275, which was previously billed. Based on this information, we decided that Medicare rules for coverage of an additional CT scan have not been met. Therefore, we decided that the Plan does not have to pay for an additional computed tomography (CT) scan (71275) provided on May 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve application of a modality to 1 or more areas; hot or cold packs (CPT code 97010 X 32), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says notes must show proof of skill. Care was needed to address the enrollee's problem and help restore their function. The Plan states the notes show the enrollee's remaining functional limitations can be addressed with their home program.

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 the services. 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 application of hot or cold packs x 32 units (CPT code 97010) does not require that the unique skills of a professional therapist are required 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 CPT code 97010 are not part of a maintenance program. Hot or cold packs (CPT 97010) are not 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve application of a modality to 1 or more areas; hot or cold packs (CPT code 97010 X 32), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric treatment.

You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient psychiatric treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, you do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of September 30, 2021 forward as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were cooperative/compliant with treatment. You were not showing any aggressive behaviors, or any treatment required for acute threats of safety.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee has stabilized medically necessary and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on March 31, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on March 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 an MRI of the lumbar spine. Our reviewer says that the services are not medically necessary. Our physician reviewer found criteria for a lumbar MRI is not met. More conservative measures are needed to include physical therapy for low back pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for end-stage renal disease (ESRD) related services provided on April 2, 2021.

You asked the Plan to waive the copayment for ESRD related services monthly (90960). You say that you do not recall this service. The Plan denied your request. The Plan says the enrollee was charged this copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $30 copayment for Physician services, specialist. 

The enrollee has been asked to pay a $30 copayment for ESRD related services monthly (90960). ESRD related services monthly (90960) falls within the Physician services, specialist benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for end-stage renal disease (ESRD) related services provided on April 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says an IRF admission is not medically necessary. The therapy can be delivered at lower level of care.
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for subdural hematoma, sternal fracture, lumbar fracture and rib fracture after a motor vehicle collision.
Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dialysis services provided on January 27, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of services at issue have not been met. Specifically, the address associated with the provider's Centers for Medicare and Medicaid Services (CMS) Certification Number (CCN) does not match the physical address of the facility or the address associated with the provider's National Provider Identifier (NPI). Therefore, we decided that the Plan does not have to pay for the dialysis services provided on January 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PBRT (CPT code 77525), for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee was staged as ER positive/PR positive/HER-2/neu negative and need proton beam therapy. The Plan denied your request. The Plan says a review of the current medical literature indicates that the standard of care for radiation therapy for breast cancer is standard radiation therapy including intensity modulated radiation therapy (IMRT). The Plan states no definitive data exists to suggest that protons are superior to photon IMRT or even EBRT for early breast cancer in either disease control or toxicity outcomes and that national guidelines suggest that outcomes for protons and IMRT are similar.
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the decision is upheld for this enrollee as proton therapy would not be "furnished in accordance with accepted standards of medical practice". 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the PBRT (CPT code 77525), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a home ventilator to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a home ventilator to be provided by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intravenous hydration services provided to the enrollee on
May 26, 2020 and billed under code 96360.

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 Medicare coverage criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct Medicare criteria. The Plan says that
based on Medicare LCD is based on services rendered in the region.

The services were rendered in the state of New Jersey, therefore the guidelines for LCD L34960 were correctly
applied and this claim cannot be paid as billed.

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, code 96360
was not billed appropriately on this claim. Therefore, we decided that the Plan does not have to pay for
intravenous hydration services provided to the enrollee on May 26, 2020 and billed under code 96360.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) medical nutrition therapy visits.

You asked the Plan to pre-approve the medical nutrition therapy visits. You say that this should be covered. You state you had unintentional unhealthy weight loss and need nutritional therapy as prescribed by your doctor. The Plan denied your request. The Plan says the documentation fails to indicate that you have qualifying diagnosis as per NCD 180.1.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medical nutrition therapy visits have not been met. You do not have a qualifying diagnosis for the services. The rules say that effective October 1, 2002, basic coverage of MNT for the first year a beneficiary receives MNT with either a diagnosis of renal disease or diabetes as defined at 42 CFR Section 410.130 is three hours, of administration. Therefore, we decided that the Plan does not have to pre-approve twelve (12) medical nutrition therapy visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT of the Thorax (71260) provided on April 22, 2021.
You asked the Plan to pay for the CT of the Thorax. You say that you would like reconsideration because CPT code 71260 is not bundled with any other service that was performed on the billed date of service. The Plan denied your request. The Plan says a Procedure to Procedure edit exists between 71275 and 71260.
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 71260 has a bundled relationship with code 71275 and cannot be paid as billed. This code cannot be paid as a separate line item. Of note, no modifier has been billed to indicate that CPT code 71260 is distinct from 71275 Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for CT of the Thorax (71260) provided on April 22, 2021.