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

We decided that the Plan does not have to waive the copayment for a stress test and to waive the coinsurance for Medicare Part B drugs provided on August 25, 2020.

You asked the Plan to waive the copayment for a stress test and to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the charges and feel that the enrollee should only owe the $160 copayment for the test. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $20 copayment for non-radiological diagnostic services. The enrollee's contract with the Plan also clearly says that enrollee's must pay 20% coinsurance for Medicare Part B prescription drugs. 

The enrollee sent Medicare Part B drugs on August 25, 2020. The total allowed amount is $459.68 and 20% of that is $91.94. 

The enrollee received a stress test on August 25, 2020. Therefore, they are responsible to pay the $20 copayment. 

The total amount the enrollee owes is: $111.94.

The enrollee has been asked to pay the total amount of $111.94 for a stress test and Medicare Part B drugs. A stress test falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 a stress test and to waive the coinsurance for Medicare Part B drugs provided on August 25, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visit (99213) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve office visit. You say that this requested procedure is medically necessary. The Plan denied your request. The Plan says they have in-network providers available to treat your medical needs.
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 office visit (99213) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on May 3 to May 
26, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that mental health coverage is important and 
that you were never advised that the Plan would deny these claims. The Plan denied your request. The Plan 
says rules for payment have not been met because the provider of the services at issue has opted out of the 
Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
psychotherapy services (90834) provided on May 3 to May 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
You asked the Plan to pre-approve Synvisc-One. You say that the requested Synvisc-One is medically necessary. The Plan denied your request. The Plan says the requested Synvisc-One is not medically necessary.
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 Synvisc-One. Our reviewer says that the requested Synvisc-One is not medically necessary. Our physician reviewer found the literature states that viscosupplementation therapy is medically necessary for the treatment of osteoarthritis in the knee. It is considered experimental and investigational for indications such as chondromalacia patellae, facet joint arthropathy, following anterior cruciate ligament reconstruction, meniscectomy, or partial or total knee arthroplasty; hemophilic arthropathy, muscle stiffness, spastic hemiparesis, osteochondritis dissecans, palendromic rheumatism, patellofemoral arthritis, patellofemoral syndrome (patellar knee pain), peripheral nerve pain, plantar nerve entrapment syndrome, psoriatic arthritis, or for use in joints other than the knee (e.g., ankle, carpo-metacarpal joint, elbow, hip, metatarso-phalangeal joint, shoulder, thumb, and temporomandibular joint) because the effectiveness of viscosupplementation for these indications has not been established. The review has determined that the documentation does not support that Synvisc-One is medically necessary or reasonable for the enrollee. The documentation does not support that Synvisc-One is safe and effective for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740).
You asked the Plan to pre-approve a crown. You say that the service should be covered. The Plan denied your request. The Plan says this is not a covered service.
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, the requested items or services are not among those covered under this benefit. Specifically, the service is not listed in the Plan's benefit chart. This means the service is not covered. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740).
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 does not meet 
criteria. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, at an intensive rehabilitation therapy program. There is no indication that you would 
participate in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly 
to regain or maintain your functional status. You can receive services 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a toilet grab bar (E0243).
You asked the Plan to pre-approve a grab bar. You say that you would like to appeal the denial of bathroom security rails. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a toilet grab bar (E0243).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the enrollee does not meet the criteria. The enrollee is not within the covered age range of 55 and 77 years of age.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above-described criteria.
We reviewed the file and the Medicare rules. We find that the enrollee is not within the covered age range of 55 and 77 years of age. In this case, the enrollee is 85 years old. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are 
no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on December 22, 2020.
You asked the Plan to pay for these services. You say that these dental services should be covered by the Plan.
The Plan denied your request. The Plan says the $1000 maximum benefit was exhausted prior to this date of
service. Maximus overturned the Plans denial stating documentation of the prior services provided were not in
the case file. The Plan requested a reopen and provided the claim information regarding your 2020 dental
service.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says the maximum dental allowance is $1000.
The Plan provided documentation to show the dental visits provided on January 7, 2020 and March 18, 2020
exhausted these benefits. Therefore, we decided that the Plan does not have to pay for dental services provided
on December 22, 2020.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for the home health services provided from June 2, 2020, to June 4, 2020. 
 
You asked the Plan to pay for the home health services. You say that this claim was denied incorrectly, and you 
would like it to be reprocessed for payment. You also say that you were not sending out Requests for 
Anticipated Payments (RAPs) last year. The Plan denied your request. The Plan says that payment for the 
previously paid RAP exceeds the total due. 
 
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 did not submit evidence that a RAP was paid for 3HC11 for this date 
range, and the documentation does not show that records were requested. Without this information we cannot 
determine that the Plan's coverage rules support the denial of payment in this case. Consequently, the Plan has 
not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the 
home health services provided from June 2, 2020, to June 4, 2020.  
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI scan of the shoulder (73222).
You asked the Plan to pre-approve an MRI scan of the shoulder. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested service have 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 scan of the shoulder. Our reviewer says that the requested service is not medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation of adequate conservative measures for shoulder pain. At least a 6-week trial of physical therapy is needed. 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 scan of the shoulder have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI scan of the shoulder (73222).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 28, 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 procedure code 23430 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 23430 (tenodesis of long tendon of biceps) and 23472 
(total shoulder arthroplasty). Code 23430 is a column II code with a modifier indicator of 1 when billed with 
column I code 23472. Code 23430 was not billed with an appropriate modifier to allow for separate payment. 

Therefore, we decided that the Plan does not have to pay for the surgical services rendered on January 28, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in bathtub.
You asked the Plan to pre-approve a walk-in bathtub. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk-in bathtub.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas NeoGen therapy with Nutri-Pharmaceutical 
injections (99212, 97112, 97032, 97016, 96372, J3490, J3420, J3415, and J4411) provided on March 18, 2021.

You asked the Plan to pay for the Sanexas NeoGen therapy with Nutri-Pharmaceutical injections. You say that 
you would like reconsideration because the services rendered were medically necessary. The Plan denied your 
request. The Plan says the denial of Sanexas neoGen-Series Therapy (electrical cell stimulation), 
vasopneumatic device therapy, and the associated codes for the subcutaneous injection of Nutri-Pharmaceutical 
blend was appropriate given the clinical scenario and the guidance presented. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical 
therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private 
practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that 
NP/PA may perform physical therapy services under State law. The rules also say that claims for compounded 
drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Sanexas NeoGen therapy with Nutri-Pharmaceutical injections have not been met. Specifically, 
review of the file and publicly available records, we find that the physical therapy services at issue in this case 
were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Tennessee. 
Additionally, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin 
syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. 
As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as 
billed, the drug administration code, 96372, also cannot be paid. Finally, the office visit at issue was billed with 
modifier 25, which is used to report a significant, separately identifiable Evaluation and Management (EM) 
service by the same physician or other qualified health care professional on the same day of a procedure or 
other service. There is no documentation of any significant, separately identifiable evaluation unrelated to the 
treatment provided to the enrollee on this date of service. Therefore, we decided that the Plan does not have to 
pay for the Sanexas NeoGen therapy with Nutri-Pharmaceutical injections (99212, 97112, 97032, 97016, 
96372, J3490, J3420, J3415, and J4411) provided on March 18, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after October 26, 2021.
You asked the Plan to pre-approve the continuation of SNF care. You say that you continue to require 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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 64-year-old female with a past medical history of hypertension, coronary artery disease, peripheral artery disease, end stage renal disease on dialysis and prior stroke who was admitted to a skilled nursing facility for skilled nursing and therapy services on September 20, 2021, after treatment in an acute hospital for pneumonia and cellulitis/osteomyelitis of the right great toe. While you do continue to require skilled therapy services, there is no documentation that you continue to require skilled nursing services. In addition, based on the medical records provided daily skilled services are not required. In conclusion, you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case. 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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after October 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services after October 28, 2021.
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 admission 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to the SNF on October 7, 2021 after hospitalization for endometrial cancer. You received oral medications and had stable vital signs. You received physical and occupational therapy in the SNF. By the dates in question, you need minimal assistance with bed mobility and are dependent or require a Hoyer lift for transfers. You need varied assistance with activities of daily living. You have no skilled nursing or skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services after October 28, 2021.