Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on March 4, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from February 16, 2022, forward.  You asked the Plan to pre-approve inpatient psychiatric care from February 16, 2022, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.  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 care from February 16, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of February 16, 2022, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond February 16, 2022, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis.  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 care from February 16, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from February 16, 2022, forward.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.  You asked the Plan to pre-approve the SNF admission. You say that the family is working to take the enrollee home with VA personal care which takes 2-3 weeks to obtain. The enrollee needs continued therapy and care 24/7 until that can be coordinated with the VA. The Plan denied your request. The Plan says NF admission not medically necessary and care can be provided at home with home health services or outpatient therapy  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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. The enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of care (ex. HHS, AL, LTC).  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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided October 30, 2021.  You asked the Plan to pay for the comprehensive oral exam. You say that you were not told that you could not have a dental consultation covered by the Plan. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers the comprehensive oral exam once every six months.     We looked at the file and Medicare rules. You previously had a dental exam covered on July 26, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided October 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injections (62320), provided on September 20, 2021.  You asked the Plan to pay for the injections. You say that the service was medically necessary. The Plan denied your request. The Plan says no medical records were submitted to support medical necessity of this service.  The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case.   Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary.  Therefore, we decided that the Plan does not have to pay for the injections (62320), provided on September 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for professional interpretation of magnetic resonance (eg, proton) imaging (MRI), lower extremity, code 73720-26, for date of service April 27, 2021.  You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare Guidance says services must be verified in the submitted physician documentation. This is an administrative determination for coding or billing. Review of the available clinical case notes and records show this is an appeal for payment of the professional interpretation of magnetic resonance (eg, proton) imaging (MRI), lower extremity, code 73720-26, for date of service April 27, 2021.  The claim records show the enrollee had a professional interpretation of a femur MRI on April 27, 2021. The submitted documentation supports 1 (one) unit of 73720-26, which was previously approved and paid. There is no documentation to show this was a separate and distinct service.   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, the records provided do not support the services billed. The Plan provided documentation to show this service was previously paid. Therefore, we decided that the Plan does not have to pay for professional interpretation of magnetic resonance (eg, proton) imaging (MRI), lower extremity, code 73720-26, for date of service April 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance oxygen supplies (A0422) provided on October 20, 2020.  You asked the Plan to pay for the ambulance oxygen supplies. You say that you would like reconsideration because the ambulance services were medically necessary. The Plan denied your request. The Plan says oxygen and other items and services provided as part of the transport are included in the base payment rate and are not separately payable.  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 A0422 is ambulance (als or bls) oxygen and oxygen supplies, life sustaining situation.  We find that CPT code A0422 is not supported in the medical record. Specifically oxygen and supplies are included in the base payment for the ambulance services. Separate payment is not made for oxygen supplies. Based on this information, we decided that Medicare rules for coverage of the ambulance oxygen supplies have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance oxygen supplies (A0422) provided on October 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tie down kit for the enrollee.

You asked the Plan to pre-approve a tie down kit. You say that this is necessary for the enrollee. The Plan denied your request. The Plan says that this is not medically necessary and not covered by Medicare.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a tie down kit for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for domiciliary or rest home visit (99337) provided on March 27, 2021, to April 15, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for domiciliary or rest home visit. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.  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 domiciliary or rest home visit (99337) provided on March 27, 2021, to April 15, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance oxygen supplies (A0422) provided on October 20, 2020.  You asked the Plan to pay for the ambulance oxygen supplies. You say that you would like reconsideration because the ambulance services were medically necessary. The Plan denied your request. The Plan says oxygen and other items and services provided as part of the transport are included in the base payment rate and are not separately payable.  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 A0422 is ambulance (als or bls) oxygen and oxygen supplies, life sustaining situation.  We find that CPT code A0422 is not supported in the medical record. Specifically, oxygen and supplies are included in the base payment for the ambulance services. Separate payment is not made for oxygen supplies. Based on this information, we decided that Medicare rules for coverage of the ambulance oxygen supplies have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance oxygen supplies (A0422) provided on October 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the selective catheter placement (36245) and moderate sedation services (99153) provided on August 5, 2021  You asked the Plan to pay for the selective catheter placement (36245) and moderate sedation services (99153). You say that the patient had multiple exams on this date. You say that the attached reports support the level of service and should be reconsidered. The Plan denied your request. The Plan says an appropriate modifier was not billed with CPT code 36245. The Plan also says that CPT code 99153 was not billed as required by Medicare.  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 36245 is a column II code to column I code 36247. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria for CPT code 36245 have not been met.   We looked at your request for CPT code 99153 and have determined that Medicare criteria for coverage have not been met. Specifically, CPT code 99153 is a TC only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Therefore, we decided that the Plan does not have to pay for the selective catheter placement (36245) and moderate sedation services (99153) provided on August 5, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex device placement surgery for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex device placement surgery for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.  You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode that could be delivered by BiPAP is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 a portable ventilator is not medically reasonable and necessary. There is no documentation to suggest a BiPAP with back up rate and AVAPS was utilized. This patient does not have a neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease.   Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable ventilator.  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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an IRF admission and services.  You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says an IRF admission is not medically necessary.  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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for metabolic encephalopathy, hypotension, and pneumonia. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee 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 an IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided the Plan does not have to provide coverage for skilled nursing facility services requested in April
of 2021.
You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility
services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are
not met. 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. At issue is coverage for SNF services.
Our Physician Reviewer determined there were documented skilled therapy needs. The Plan
requested a reopen and argued that the surgeon stated, in medical records dated April 22, 2021, that the bypass
graft had clotted, and that further evaluation and management were needed. The Plan states that you were not
medically stable and needed further surgical intervention in the hospital. The Plan is correct in this case. It is
documented in the medical record dated April 22, 2021, that you were to remain in the hospital with minimal
ambulation allowed due to a thrombosed graft. At the time of the request for skilled nursing admission, you
were not yet appropriate for skilled nursing facility 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 skilled nursing facility services have not been met. Therefore, we decided that
the Plan does not have to pre-approve skilled nursing facility services requested in April of 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Monovisc (J7327).  You asked the Plan to pre-approve Monovisc. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria 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 Monovisc. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee has osteoarthritis of the knee.  The requested medication is a new start.  The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Monovisc (J7327).
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 will benefit from at least 3 hours of therapy per day which cannot be provided at a lower level of care. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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 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 you may need physical and/or occupational therapy, there is no documented need for an intensive 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.