Persius/hicric huggingface dataset:
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 services. You say that the enrollee needs physical and occupational therapy. The Plan denied your request. The Plan says that the record does not show that the enrollee requires daily skilled nursing or skilled therapy in a SNF setting.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for tibia repair surgery (27720) provided on March 11, 2021.  You asked the Plan to pay for tibia surgery. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation does not support this code.  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 27720 is repair of nonunion or malunion, tibia; without graft (e.g., compression technique).  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 tibia surgery.  Our reviewer says that this code does not meet the criteria for payment. Our reviewer found the operative report does not include enough documentation to confirm that a repair of nonunion was performed.  Per operative report "The tibia was then treated with compression by turning the spatial frame struts to treat the left tibial nonunion with compression technique".  Operative report does not describe details per Correct Coding Initiative Policy Manual: "pieces of bone rotated into position and stabilized with a metal plate and screws" Therefore, this procedure cannot be confirmed as performed.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tibia surgery have not been met. Therefore, we decided that the Plan does not have to pay for tibia repair surgery (27720) provided on March 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcatheter aortic valve replacement (TAVR) procedure.
You asked the Plan to pre-approve a transcatheter aortic valve replacement (TAVR) procedure. You say that this procedure is medically necessary. The Plan denied your request. The Plan says this procedure is not covered by Medicare. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. Our Medical Director has concluded that the Plan is correct in this case. Medicare coverage TAVR for symptomatic aortic valve stenosis. The medical records do not show a diagnosis of symptomatic aortic stenosis. The procedure is off-label and considered investigational in the setting of aortic insufficiency. 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 transcatheter aortic valve replacement (TAVR) procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a transcatheter aortic valve replacement (TAVR) procedure.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genetic testing services.  You asked the Plan to pre-approve the requested services. You say that the enrollee has a history of blood clots. The Plan denied your request. The Plan says the tests are not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file, and Medicare rules. There is insufficient evidence in the published peer-reviewed scientific literature to support coverage for genetic testing for inherited thrombophilias outside the pregnant women.  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 genetic testing services.
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 you are scheduled to be discharged from the hospital and need inpatient rehabilitation in order to get strong enough to go home. The Plan denied your request. The Plan says the criteria for admission to the IRF are not met. Your ongoing skilled therapy and nursing needs can be provided at a skilled nursing facility.  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. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a retreatment of previous root canal therapy (D3348) and a porcelain fused to predominantly base metal crown (D2751) for tooth #3.  You asked the Plan to pre-approve restorative services for tooth #3. You say that these services are necessary for this tooth. The Plan denied your request. The Plan says tooth #3 has too little bone in the middle of the roots. The requested services are not medically necessary as this tooth has a poor long-term prognosis and is unlikely to be saved with this treatment.  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. The Plan covers restorative services for tooth #3 when the services are medically necessary and reasonable.   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 restorative services for tooth #3. Our reviewer says that the criteria for coverage for these services have not been met. Our physician reviewer found a review of your record and x-rays indicate that the caries in tooth #3 appear to extend into the furcation area of the roots, making for a poor prognosis for retention of tooth #3, even if these services were to be provided.  The services indicated are not medically reasonable in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of restorative services for tooth #3 have not been met. Therefore, we decided that the Plan does not have to pre-approve a retreatment of previous root canal therapy (D3348) and a porcelain fused to predominantly base metal crown (D2751) for tooth #3.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from July 1, 2021, to July 5, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you should not have been discharged after your surgery, and this should be considered a part of that initial stay. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $350 per day for days 1-5 and $0 per day after day 5 for inpatient hospital care.   Your hospital stay lasted five days, but there is no copayment for the date of discharge. Therefore, you have been asked to pay $350 per day for four days of inpatient hospital services. The total for your stay is $1400. Inpatient hospital services fall within the Inpatient Hospital Care 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 copayment for inpatient hospital services provided from July 1, 2021, to July 5, 2021.   Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Hyalgan (J7321).  You asked the Plan to pre-approve Hyalgan. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been 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 Hyalgan. Our reviewer says that the requirements for coverage of Hyalgan have not been met. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective or have adverse effects for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan (J7321).
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to waive the deductible for the chiropractic services you received on January 13, 2021.  You asked the Plan to waive the deductible for the chiropractic services. You say that this provider has been your doctor for many years and you were not aware that he no longer took your insurance. The Plan denied your request. The Plan says that you are responsible for 20% coinsurance after your deductible.  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. Specifically, plans are only permitted to charge cost sharing when that cost sharing has been clearly disclosed to their members.  The Plan alleges that you have a deductible that applies to these services.  The case file that the Plan sent us included an Evidence of Coverage booklet that is supposed to lay out your cost sharing obligations.  This booklet was silent on the issue of a deductible.  We sent a Request for Information to the Plan to confirm that 1. the Plan had sent to us the correct Evidence of Coverage; and 2. that there is no other documentation that proves that a deductible applies to these services.  The Plan's response was unsatisfactory.  They did not respond to whether or not the Evidence of Coverage they provided to us was accurate.  All they sent in response to the second issue is a screen capture of 3 lines of these Benefit Grid that stated that members pay 20% coinsurance after the deductible for chiropractic services.  Nowhere in this benefit grid does it explain what your deductible is.  Nowhere in the case file does it provide evidence that you had not met this deductible.  Finally, the Plan has provided no evidence that members are even given access to this benefit grid, so we cannot tell if this cost sharing obligation was properly disclosed to you.  Therefore, we decided that the Plan has to waive the deductible for the chiropractic services you received on January 13, 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: Practitioner Services
Decision: Favorable

 We decided that the Plan has to waive the copayment for an office visit (99211, G8417, G8428) rendered on April 6, 2021.  You asked the Plan to waive the copayment for an office visit with a specialist. You say that you feel you should not have a copayment The Plan denied your request. The Plan says that you were charged the correct cost sharing amount  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay $0 copayment for each Medicare-covered primary care office and a $0 copayment for each Medicare-covered specialist visit.   The Plan says you must pay $34 in coinsurance for an office visit. Based on the Plan contract, however, you cannot be asked to pay more than $0 copayment for an office visit. Therefore, we decided that the Plan has to waive the copayment for an office visit (99211, G8417, G8428) rendered on April 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (43239) provided on June 21, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 of code 43239 is "Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple".  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 services. Our reviewer says that the use of code 43239 is not supported by the records provided. Our reviewer found that the medical records provided do not include sufficient documentation to validate that an "Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple", was performed June 21, 2021. Therefore, this service cannot be verified.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (43239) provided on June 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a 77-year-old male with a past medical history of primary adrenocortical insufficiency and atrial fibrillation who presented to the acute hospital on November 30, 2021, with weakness, shortness of breath, acute respiratory failure, recent coronavirus infection, volume depletion and diarrhea. He was treated in the hospital with supplemental oxygen, intravenous fluids and hydrocortisone and improved. Although this patient does require skilled therapy services, these services are not required on a daily basis. Based on the medical records provided this patient does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or 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 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the hanger cover (K0108).  You asked the Plan to pre-approve the hanger cover. You say that you need this item. The Plan denied your request. The Plan says this item does not primarily serve a medical purpose.  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 the hanger cover (K0108).
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg injection for the enrollee.  You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that [Enter plan denial rationale, e.g. "...rules for SNF care 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 the injection. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found vaginal cancer is treated the same as cervical cancer. For first line metastatic disease, the standard of care is platinum based therapy with bevacizumab. The combination is usually cisplatin or carboplatin with paclitaxel and bevacizumab (or biosimilar). The service is reasonable and 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 injection have been met. Therefore, we decided that the Plan has to pre-approve Bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg injection for the enrollee.   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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on June 24, 2021.  You asked the Plan to pay for the office visit. You say that the enrollee was struggling to find an in-network provider for this care, and received these services from an out-of-network provider after other options were exhausted. The Plan denied your request. The Plan says that they have agreed to make an exception in this case and provide reimbursement for these services at the in-network rate, and has provided information for an in-network provider for these services going forward. Payment has been issued for the oral device; however, the office visit in this case was billed incorrectly. Payment cannot be made for this service unless a corrected claim form is submitted, as the provider is out-of-network and the code submitted is not payable as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, code 99201 was submitted in association with the office visit. Per the CPT Code Manual, code 99201 not a code connected to any service that is payable by Medicare. This code is invalid and does not reflect any service.  Providers must report services correctly. The Plan cannot be expected to pay for a service that is billed with a non-existent procedure code. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met.  Payment may be made for this service if a corrected claim is submitted directly to the Plan, but payment cannot be made for this service as currently billed. Therefore, we decided that the Plan does not have to pay for the office visit provided on June 24, 2021.