Persius/hicric huggingface dataset:
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 enrollee cannot be adequately care for in her current condition at a lower level of care. The Plan denied your request. The Plan says the enrollee has not completed the full course of care in the hospital.
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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for aspiration. The enrollee has anoxic brain injury, a tracheotomy and feeding tube at baseline. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on April 21, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that the member needed to be seen due to a medical necessity. The Plan denied your request. The Plan says services should be received from network providers who are listed in the provider directory, except when urgent or an emergency
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit (99213) provided on April 21, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure
(CPAP) device (E0601) and a humidifier (E0562) provided on April 15, 2021, to May 15, 2021.

You asked the Plan to waive the coinsurance for a CPAP device and a humidifier. You say that you never used
the equipment because you had an allergic reaction and would like the coinsurance waived. The Plan denied
your request. The Plan says the coinsurance you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for each durable medical equipment (DME) and related supplies.

You have been asked to pay a 20% coinsurance for a CPAP device and a humidifier. The records show that the
coinsurance was assessed for the rental of the DME equipment for April and May. The allowed amount of the
claim for each month is $63.72, resulting in a coinsurance obligation of $12.75 per month. Your total costshare
is $25.50 ($12.75 x 2-month rental = $25.50). The records also show the equipment was returned June
15, 2021 and no further cost-share was assessed. The EOC confirms 20% is the required coinsurance for this
service. A CPAP device falls within the durable medical equipment (DME) and related supplies 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 coinsurance for a continuous positive airway pressure (CPAP)
device (E0601) and a humidifier (E0562) provided on April 15, 2021, to May 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 the records show that you were admitted to the hospital on August 28, 2021 with chronic constipation. You received oral medications and had stable vital signs. You received routine catheter care and were treated for a urinary tract infection (UTI) and constipation. You have no skilled nursing needs. You have skilled therapy needs but do not require 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 a skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having urothelial carcinoma (CPT code 0012M) provided to the enrollee on February 5, 2021.

You asked the Plan to pre-approve the laboratory services. You say that the services rendered are eligible for payment and meet medical necessity. The Plan denied your request. The Plan says your request is not a covered benefit because this test has been determined not to be clinically valid and is a non-covered test.

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 laboratory services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that a review of the medical literature and clinical practice guidelines does not support the clinical utility of Cxbladder test is a urine-based assay for the diagnosis and management of bladder cancer. In the US, National Comprehensive Cancer Network guidelines have recognized it as an appropriate diagnostic test for the monitoring for recurrence of bladder cancer. The items/services at issue in this case are not medically reasonable and 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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pre-approve Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having urothelial carcinoma (CPT code 0012M) provided to the enrollee on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99212) provided March 22, 2021.

You asked the Plan to pay for the chiropractic services. You say that this provider has been treating you for sciatica problems. The only other option is to have back surgery. This treatment has kept you on your feet and able to take care of yourself. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99212) provided March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test (G0480) provided on April 20, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a drug test. You say that you were not aware of the requirement of obtaining a prior authorization. You also say that you perform services certified by the treating physician as medically required. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a drug test (G0480) provided on April 20, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial lower denture (D5214) provided on March 22, 2021.
You asked the Plan to pay for the denture. You say that this denture was necessary, and you did not know it would not be covered. The Plan denied your request. The Plan says dentures are not covered by your dental benefit.
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. Therefore, we decided that the Plan does not have to pay for the partial lower denture (D5214) provided on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial observation care provided on May 10, 2021 by an out-of-network provider.
You asked the Plan to pay for initial observation care (99220). You say that your provider rendered services to the enrollee in good faith. The Plan denied your request. The Plan says you did not request prior authorization as required.
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for initial observation care provided on May 10, 2021 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for treatment with the Sanexas procedure provided on June 30,
2020.
You asked the Plan to pay for Sanexas. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says these services are considered investigational and are not eligible for
coverage.
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for outpatient physical therapy
services only if they are furnished by, or under the direct supervision of, a physical therapist or a nurse
practitioner (NP) or physician assistant (PA) when that practitioner may perform physical therapy services under state law. Medicare rules say that claims for compounded drugs shall be submitted using a compounded
drug code. We looked at the file and Medicare rules. 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 Ohio. 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. Based on this information, we decided that Medicare rules for coverage of Sanexas have not been met. Therefore, we decided that the Plan does not have to pay for treatment with the Sanexas procedure provided on June 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a Tempus gene panel (81225, 81226, 81227, 81230, 81231, 81381) provided on February 17, 2021.

You asked the Plan to pay for a Tempus gene panel. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so 1 code must be submitted for the panel. 

We find that CPT codes 81225, 81226, 81227, 81230, 81231, 81381 are not supported in the medical record. Specifically, these codes were used to report a panel, which should be billed with a single code. Based on this information, we decided that Medicare rules for coverage of a Tempus gene panel have not been met. Therefore, we decided that the Plan does not have to pay for a Tempus gene panel (81225, 81226, 81227, 81230, 81231, 81381) provided on February 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Truxima.

You asked the Plan to pre-approve Truxima. You say that the requested Truxima is medically necessary. The Plan denied your request. The Plan says the requested Truxima is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Truxima. Our reviewer says that the requested Truxima is not medically necessary. Our physician reviewer found the record indicates that the enrollee has autoimmune retinopathy. The Food and Drug Administration has not stated that the requested drug is approved for this indication. The Medicare approved drug compendia do not contain a positive citation for the use of the requested drug for this indication. 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 Truxima have not been met. Therefore, we decided that the Plan does not have to pre-approve Truxima.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 the enrollee was admitted to the hospital after a stroke with resulting weakness. The recent therapy notes document that he needs moderate asst with bed mobility and maximum assist for transfers. He uses a wheelchair for mobility. He is medically stable with no skilled nursing needs. He has skilled therapy needs and has been receiving skilled therapy services in an inpatient rehabilitation facility. There is no indication that the enrollee requires a transfer to a SNF for daily skilled therapy. The enrollee does 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 a skilled nursing facility (SNF) admission.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for three (3) emergency ambulance transportation services (A0428, A0425) provided on March 27, 2021, to March 29, 2021.
You asked the Plan to waive the copayment for ambulance transportation services. You say that the enrollee was in the hospital three days in a row and sent home each of those days. You also say the hospital never kept him for observation or even considered it. The Plan denied your request. The Plan says the copayments you are being charged are correct.
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 $100 copayment for each one-way trip for Medicare-covered ambulance services. You do not pay this copayment if you are admitted as an inpatient to the hospital within 24 hours or are held overnight at the hospital for observation or for trips between hospitals and/or skilled nursing facilities. The enrollee has been asked to pay a $100 copayment for each emergency ambulance transportation service. The records show that the enrollee was transported to the hospital via an ambulance on three separate days. The EOC confirms $100 is the required copayment for these services per one-way trip. 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 three (3) emergency ambulance transportation services (A0428, A0425) provided on March 27, 2021, to March 29, 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: 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 a skilled nursing facility cannot meet the oxygen demands of the enrollee. The Plan denied your request. The Plan says admission to LTACH is denied as not meeting criteria and not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee continues to require high flow oxygen. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous positive airway pressure (CPAP) machine and humidifier.
You asked the Plan to pre-approve a CPAP machine and humidifier. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says that the services are not covered.
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 rules say that more extensive maintenance which, based on the manufacturers' recommendations, is to be performed by authorized technicians, is covered as repairs for medically necessary equipment which a beneficiary owns. This might include, for example, breaking down sealed components and performing tests which require specialized testing equipment not available to the beneficiary. In this case, the file shows that the manufacturer has issued a recall on the enrollee's current device that the enrollee is not able to correct on their own. Therefore, we decided that the Plan has to pre-approve a continuous positive airway pressure (CPAP) machine and humidifier.
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.