Persius/hicric huggingface dataset:
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 the enrollee does not require IRF level of therapies consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from continued physical therapy, and occupational therapy, her rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 an expandable controller (E2377), harness (E2313), electronic connection (E2311), Q logic controller (K0108), retractable lap belt (K0108), and calf rest (E0995).  

You asked the Plan to pre-approve a expandable controller, harness, electronic connection, Q logic controller, retractable lap belt, and calf rest. You say that the items are medically necessary. The Plan denied your request. The Plan says there is no medical need to control the power options through a joystick and the Q logic controller, lap belt, and calf rest are included with the wheelchair and can be requested separately.  

The Plan must follow Medicare rules. Medicare rules say that there must be a medical need to control options through a joystick and column two codes are not separately payable from their column one code.  

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. Our reviewer says that the items are not medically necessary. Our physician reviewer found there is no documentation indicating a medical need to control the power options through a joystick.  

We looked at this physician's review, file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a expandable controller, harness, electronic connection, Q logic controller, retractable lap belt, and calf rest have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), electronic connection (E2311), Q logic controller (K0108), retractable lap belt (K0108), and calf rest (E0995).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Cxbladder Monitor test (CPT code 0012M) provided to the enrollee on July 6, 2021.  

You asked the Plan to pay for the Cxbladder Monitor test. You say that the service should be covered based on Medicare guidelines. The Plan denied your request. The Plan says the Cxbladder Monitor test is not covered by Medicare. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Cxbladder Monitor test have not been met. The rules say non-coverage reaffirmed for CPT codes 0012M and 0013M for CxBladder. Therefore, we decided that the Plan does not have to pay for the Cxbladder Monitor test (CPT code 0012M) provided to the enrollee on July 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a tubing extension set (S1015) and infection control supplies (S8301) provided on June 17, 2021.  You asked the Plan to pay for a tubing extension set and infection control supplies. You say that these items were provided at your own cost for safety. The Plan denied your request. The Plan says these items were not billed with valid codes.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.   We find that CPT codes S1015 and S8301 are not supported in the medical record. Specifically, these codes have a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of a tubing extension set and infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for a tubing extension set (S1015) and infection control supplies (S8301) provided on June 17, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit (99285) provided on June 20, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 $85 per visit to an emergency room.   You have been asked to pay an $85 copayment for the emergency room visit provided. 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 the emergency room visit (99285) provided on June 20, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve arthrocentesis for the enrollee.  

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says that there is insufficient medical documentation.  

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had four weeks of physical therapy, and a prior injection which provided 80% pain relief and functional improvement. The enrollee has had an adequate trial of conservative therapy. The requested procedure is 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 procedure have been met. Therefore, we decided that the Plan has to pre-approve arthrocentesis 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.  

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the enrollee was admitted with acute respiratory failure due to interstitial pneumonia. The record indicates that the enrollee is on continuous intravenous medication to control atrial fibrillation and requires ongoing acute care services. 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 she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.  

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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (E0652) and lower garments (E0667).  

You asked the Plan to pre-approve a pneumatic compression device. You say that the items are medically necessary. The Plan denied your request. The Plan says the patient does not have lymphedema extending into the chest, trunk and/or abdomen.  

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, code E0652 is not covered for the treatment of the arms or legs and the record does not show that the enrollee has lymphedema extending into the chest, trunk and/or abdomen. Therefore, we decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (E0652) and lower garments (E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete mandibular denture (D5120) or pay more for the complete maxillary denture (D5110) provided on June 18, 2021.  

You asked the Plan to pay for the complete mandibular dentures and to pay more for the complete maxillary denture. You say that the dental office assured you that this treating provider was in-network with your plan. The Plan denied your request. The Plan says your plan has an allowance for certain dental services. The Plan also says that the annual limit allowed by your dental plan for the 2021 benefit year has been paid.  

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 Plan offers up to $750 every year for non-Medicare covered preventive and comprehensive dental services combined. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit while processing this claim for the June 18, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete mandibular denture (D5120) or pay more for the complete maxillary denture (D5110) provided on June 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient consultation services (procedure code 99253) provided to the enrollee on June 27, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the code should be included in the global surgery edit.  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 99253 is "Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 55 minutes are spent at the bedside and on the patient's hospital floor or unit."  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 services at issue in this case were not supported by the medical records. Our reviewer found CPT 99253 does not meet the criteria for billing or reimbursement consideration. The medical records provided does not include sufficient documentation to validate that CPT 99253 performed on June 27, 2021 is eligible for reimbursement.  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 inpatient consultation services (procedure code 99253) provided to the enrollee on June 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for surgical services coded as 29877.
You asked the Plan to provide coverage for services coded as 29877. You say that this surgery is medically
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that the requested surgery was not
requested for treatment of articular cartilage pathology. The soft tissue scarring and arthrofibrosis is more
appropriately addressed by a soft tissue procedure (code 29884) which had already been approved by the Plan.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. Our physician reviewer found the requested
arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) (29877) was not
demonstrated to be medically reasonable or 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 services coded as
29877 have not been met. Therefore, we decided that the Plan does not have to provide coverage for surgical
services coded as 29877.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care for days 21 to 59 of the enrollee's admission.  

You asked the Plan to waive the copayment for SNF care. You say that the enrollee really needs rehabilitation that is convenient to him due to his health. The Plan denied your request. The Plan says copayments are a fixed amount that the enrollee is responsible for, and they cannot be waived or reduced.  

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 $0 for days 1 to 20 of a benefit period, $178 per day for days 21 to 59 of a benefit period, and $0 for days 60 to 100 of a benefit period for Skilled Nursing Facility (SNF) care.   

The enrollee will be asked to pay $0 for days 1 to 20 of a benefit period, $178 per day for days 21 to 59 of a benefit period, and $0 for days 60 to 100 of a benefit period for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) care benefit category. This means that the enrollee will be 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 the skilled nursing facility (SNF) care for days 21 to 59 of the enrollee's admission.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that you need more therapy in the SNF because you feel safe enough to return home. You state that you feel you need skilled nursing care for your wound care. The Plan denied your request. The Plan says you do not meet Medicare criteria for SNF coverage under the Medicare Part A benefit. The Plan states you have not had a change in function that needs daily skilled therapy services, and no daily skilled nursing needs are noted. The Plan states based on the clinical information received, your current needs can be safely managed with an alternate level of care, such as at home or in an assisted living facility with supervision and home health services or in long-term care with part-time skilled services.  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 there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.  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 SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99213) provided on August 2, 2021.  You asked the Plan to pay for an office visit. You say that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when the Plan's vision vendor is utilized.  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of an office visit have not been met. Specifically, services were provided by an out-of-network provider and are not covered. Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on August 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal aortic aneurysm (AAA) screening (76706) provided on July 1, 2021.  You asked the Plan to pay for the AAA screening. You say that this is a preventive service. You also say that this should be covered. The Plan denied your request. The Plan says the AAA screening is a one-time benefit. The Plan also says that the frequency limit has been exceeded.  The Plan must follow Medicare rules. Medicare rules say that that plans must pay for a medical service or item if regular Medicare would pay for it.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the AAA screening have not been met. Specifically, the file shows that the frequency limit has been exceeded. The record shows that the Plan paid for an AAA screening that you received in 2018. Additionally, the record also shows that the screening in 2018 was negative. Therefore, we decided that the Plan does not have to pay for the abdominal aortic aneurysm (AAA) screening (76706) provided on July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for GeneSight pharmacogenomic testing provided on July 20, 2021.  You asked the Plan to pay for GeneSight testing. You say that no basis exists for the Plan to deny coverage of this testing. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not covered, was not billed with the appropriate coding, and was not medically necessary.  The Plan follows Medicare rules. Medicare rules state that pharmacogenomic testing may be covered under certain circumstances.  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 pay for GeneSight testing. Our reviewer says that this testing does not meet the Medicare criteria for payment. Our physician reviewer found the enrollee is a 72-year-old woman with listed diagnoses of major depressive disorder, recurrent, moderate, and generalized anxiety disorder. The case file contains a GeneSight Order Medical Necessity Documentation form, and the results of GeneSight testing. The case file does not contain additional clinical information for review. The documentation is insufficient to support that the GeneSight genetic testing was medically reasonable and necessary 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 GeneSight testing have not been met. Therefore, we decided that the Plan does not have to pay for GeneSight pharmacogenomic testing provided on July 20, 2021.