Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve high frequency chest wall oscillating device (E0483) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve high frequency chest wall oscillating device. You say that you are requesting an appeal of this denial as you are the sole provider of the prescribed device. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve high frequency chest wall oscillating device (E0483) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested CGM.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).  

You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.  

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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device may be implanted at one or two adjacent lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. The record indicates that the enrollee has multi-level disease including moderate to severe central spinal stenosis at L4-l5, the levels requested for treatment. The record does not state that the enrollee is indicated for operative intervention at no more than two levels.  

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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement power wheelchair (K0800).  

You asked the Plan to pre-approve a replacement power wheelchair. You say that the battery in your current chair is not working. The Plan denied your request. The Plan says replacement cannot be covered at this time.  

The Plan must follow Medicare rules. Medicare rules say that equipment which the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage. Replacement of equipment due to irreparable wear takes into consideration the reasonable useful lifetime of the equipment, which cannot be less than 5 years.  

We looked at the file and Medicare rules. The record does not show that your current wheelchair has been irreparably damaged or lost, and you received it in February of 2021, less than 5 years ago. Based on this information, we decided that Medicare rules for coverage of a replacement power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement power wheelchair (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an epidural steroid injection.  You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested epidural steroid injection.  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 an epidural steroid injection. Our reviewer says that the enrollee does not meet criteria for the requested epidural steroid injection. Our physician reviewer found the clinical information needed to approve the requested lumbar epidural steroid injection has not been submitted.  Based on the rules and records provided, the enrollee does not meet the coverage criteria for the requested lumbar epidural steroid injection (ESI). The review has determined that it is not medically necessary or reasonable for this enrollee to have the lumbar ESI as requested.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for specialist services provided on August 21, 2021.  You asked the Plan to waive the copayment for specialist services. You say that your physician's office was not open and you were experiencing an infection. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialist services.   You have been asked to pay a $40 copayment for specialist services. Specialist services fall within the physician/practitioner services, including doctor's office visits 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 specialist services provided on August 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips beyond the 30 one-way trips covered per calendar year.

You asked the Plan to pre-approve additional routine transportation. You say that the enrollee needs additional transportation to see multiple specialists and have labs drawn regularly. The Plan denied your request. The Plan says additional trips beyond the 30 one-way trips per year are not covered.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 30 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips beyond the 30 one-way trips covered per calendar year.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve home ventilator. You say that use of this machine greatly reduces hospitalizations and increases quality of life. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because a ventilator set in average volume-assured pressure support (AVAPS) mode that could be delivered by a bilevel positive airway pressure (BiPAP) device is not covered.

The Plan must follow Medicare rules. Medicare rules say that a ventilator is not covered when used to provide positive airway pressure (PAP) therapy. 

We looked at the file and Medicare rules. The requested ventilator is not covered by Medicare for PAP therapy. The Plan says that they would consider approval of an E0471 positive airway pressure device upon request. Please contact the Plan for more information about the enrollee's treatment option. Based on this information, we decided that Medicare rules for coverage of home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99214) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that you require the office visit urgently due to ongoing tinnitus. The Plan denied your request. The Plan says there are network providers available.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office visit (99214) to be provided by an out-of-network (OON) provider.
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 an admission to an inpatient rehabilitation facility is medically necessary. The Plan denied your request. The Plan says the enrollee does not need physician supervision three times per week for ongoing management of any active or acute exacerbations of chronic medical conditions.  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 has a past medical history of multiple sclerosis and is living at home with no current services. The enrollee's medical problems are stable and there are no complex nursing or rehabilitation needs.  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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the unclassified drug injection provided on September 30, 2020.  You asked the Plan to pay for the unclassified drug injection. The Plan denied your request. The Plan says the billed service 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 J3490 is drugs unclassified injection.     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 unclassified drug injection. Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the documentation shows Preservative Free Hydromorphone HCI 1mg/ml 40 MG was given. Our reviewer says that there is a more appropriate HCPCS code to report for the service provided, therefore J3490 would not be covered.  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 unclassified drug injection have not been met. Therefore, we decided that the Plan does not have to pay for the unclassified drug injection provided on September 30, 2020.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided on September 22, 2020.  You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on September 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on April 7, 2018.

You asked the Plan to waive the copayment for ambulance services. You say that this was an emergency and you should only owe 10% of the bill or $70. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for ambulance services. 

You have been asked to pay $275, which is less than the $350 copayment for ambulance services. Ambulance services fall within the ambulance services 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 ambulance services provided on April 7, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve canal preparation and fitting of preformed dowel or post (D3950) and porcelain fused to high noble metal crown (D2750) for tooth #8.  You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan denied your request. The Plan says the requested canal preparation and fitting of preformed dowel or post is not a covered service under your dental benefit. In addition, you previously had a crown for tooth #8 in November 2020. This service may only be covered once per tooth every 5 years. Therefore, these services are denied.  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 or are requested in a frequency that exceeds what is covered by this benefit. Documentation shows that you previously had a crown provided for tooth #8 less than five years ago. Therefore, we decided that the Plan does not have to pre-approve canal preparation and fitting of preformed dowel or post (D3950) and porcelain fused to high noble metal crown (D2750) for tooth #8.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the pharmacogenomics testing provided on June 9, 2021.

You asked the Plan to pay for the pharmacogenomics testing. You say that this was medically necessary to judge drug interactions as ordered by the treating physician. The Plan denied your request. The Plan says that the rules say that testing panels must be billed with a single code.

Maximus reviewed the rules cited by the Plan, and we find that these do not apply to this type of testing. In fact, the rules appear to indicate that panels may be billed using a single code, or by individual billing of the genes tested. Since there is no valid billing rule which precludes payment of the claim as billed, the plan-directed care rules below apply.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 

The enrollee was referred for the pharmacogenomics testing by a contract provider. The file does not show that the plan provided notice that the pharmacogenomics testing would not be covered. Under Medicare rules, this means the pharmacogenomics testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for the pharmacogenomics testing provided on June 9, 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a lightweight portable oxygen concentrator.  You asked the Plan to pre-approve the requested item. You say that the item is necessary when leaving the home. The Plan denied your request. The Plan says an additional portable oxygen concentrator is not medically necessary.  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.  The file shows that you have a stationary oxygen concentrator and portable oxygen tanks. The items you already have serve the same purpose as the requested item. Therefore, we decided that the Plan does not have to pre-approve a lightweight portable oxygen concentrator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital care at diagnosis related group (DRG) 056.  

You asked the Plan to pay for inpatient care. You say that the documentation supports diagnosis code N17.9. The Plan denied your request. The Plan says the denial of payment for this inpatient DRG is correct, because N17.9 is not supported as a secondary diagnosis and has been removed.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    

In this case, you billed the inpatient services provided with N17.9 - acute kidney failure, unspecified. 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 inpatient care. Our reviewer says that this inpatient stay does not meet criteria for DRG 056. Our physician reviewer found acute kidney injury is defined as any of the following: increase in serum creatinine by 0.3mg/dL or more within 48 hours, increase in serum creatinine to 1.5 times baseline or more within the last 7 days, or urine output less than 0.5 mL/kg/h for 6 hours. Laboratory results and provider documentation were reviewed and does not meet the criteria.   

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care at diagnosis related group (DRG) 056.