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

 We decided that the Plan does not have to pay for Cxbladder Monitor test (CPT code 0012M) provided to the enrollee on June 15, 2021.  

You asked the Plan to pay for the testing. You say that the service was medically necessary. The Plan denied your request. 

The Plan says the test is not approved.  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 testing have not been met. Non-coverage of code 0012M for Cxbladder was reaffirmed by Medicare. Therefore, we decided that the Plan does not have to pay for Cxbladder Monitor test (CPT code 0012M) provided to the enrollee on June 15, 2021.
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 IRF services are medically necessary. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided in a lower level of care.  

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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for hereditary assessment for cardiac conditions (CPT code(s): 81401, 81403, 81404, 81405, 81406, 81407, and 81408) provided to the enrollee on April 29, 2021.  

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says there is no Medicare benefit for screening CV risk assessment testing for asymptomatic (without signs or symptoms of disease) patients. The Plan states screening asymptomatic patients for cardiovascular risk is statutorily excluded by Medicare and will not be addressed in this policy.  

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, the laboratory services, 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 hereditary assessment for cardiac conditions (CPT code(s): 81401, 81403, 81404, 81405, 81406, 81407, and 81408) provided to the enrollee on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service (CPT code 99051C) provided to the enrollee on February 1, 2021.  You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says this service is included in another service provided at the same time and Is not allowed separately.  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 99051 is a bundled code with another procedure not specified. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service (CPT code 99051C) provided to the enrollee on February 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ankle surgery services provided on May 15, 2021.  You asked the Plan to pay for the services provided. You say that the decision to perform the procedure occurred following the enrollee's evaluation. The Plan denied your request. The Plan says the claim is not payable as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of code 27810 is closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); with manipulation. We find that CPT code 27810 was not billed with an anatomic modifier. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the ankle surgery services provided on May 15, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the left shoulder.  

You asked the Plan to pre-approve an MRI. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.  

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI. Our reviewer says that the documentation supports that the requested MRI is medically reasonable and necessary. Our physician reviewer found you have a history of left shoulder pain for a couple months. Plain films show mild degenerative changes both Acromioclavicular (AC) and glenohumeral joints. Home physical therapy exercises have been tried under the supervision of your wife who is a physical therapist but have exacerbated the symptoms. You meet criteria for the requested MRI without completing the physical therapy course. You have significant weakness in abduction and external rotation which are physical findings highly suggestive of rotator cuff tear. Therefore, you meet criteria for the requested MRI.  

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 MRI have not been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the left shoulder.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the denosumab injection you received on July 22, 2021.  You asked the Plan to waive the coinsurance for the denosumab injection. You say that the doctor didn't submit a pre-authorization for the injection. The Plan denied your request. The Plan says this claim was not denied, rather, this amount represents your appropriate coinsurance.  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 20% coinsurance for Medicare Part B drugs.   You have been asked to pay 20% coinsurance for the denosumab injection. The denosumab injection falls within the Medicare Part B drugs 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 the denosumab injection you received on July 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  

You asked the Plan to pre-approve SNF services. You say that it is not safe to return home. You say that it is medically necessary to be continually monitored by SNF staff. The Plan denied your request. The Plan says you can safely receive the services needed in the current inpatient rehabilitation facility (IRF) setting.  

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and had clear lungs. The enrollee received physical therapy, speech therapy, and occupational therapy. The enrollee was at a supervision/stand by assist level for functional mobility. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pharmacogenetic testing provided on June 17, 2021.  

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one CPT code must be submitted for the panel.  

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 looked at the file and the rules. that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the lab shall report only one code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenetic testing provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for Medicare Part B drugs.

You asked the Plan to reduce this coinsurance. You say that you do not believe this coinsurance is correct. The
Plan denied your request. The Plan says this coinsurance was charged based on the services provided, the type
of drugs provided and the Plan contract agreement. The Qualified Independent Contractor partially overturned the Plans denial. The Plan requested a reopen and provided additional information.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay 20% coinsurance for
chemotherapy drugs and administration. 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 reduce any of the coinsurance for Medicare Part B drugs
and services provided on February 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical therapy (PT) home care services provided from June 3, 2021, to July 29, 2021.  You asked the Plan to pay for the PT home care services. You say that the benefits of PT allow you to not regress/revert or have atrophy set in. The Plan denied your request. The Plan says the medical necessity for the requested services has not been established.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 the PT home care services. Our reviewer says that the documentation does not support that the presence of a home health physical therapist was medically necessary or reasonable. Our physician reviewer found you are diagnosed with a chronic, incurable, neurologic disease. You are noted to be homebound, bed/chair bound and non-ambulatory. Our reviewer found that during the period in question, the visiting home health physical therapist routinely performed your home exercise program (HEP) with you. Our physician reviewer also found that there is no evidence that you and your caregivers are unable to carry out the HEP.  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 PT home care services have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) home care services provided from June 3, 2021, to July 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for an abdominal ultrasound (76705) provided on July 21, 2021.  

You asked the Plan to pay for an abdominal ultrasound. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is 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, we have confirmed that code 76705 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an abdominal ultrasound (76705) provided on July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), each additional site (List separately in addition to code for primary procedure) (CPT code 88334) provided to the enrollee on May 27, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says procedure code 88334 26 denied on the claim for May 27, 2021 denied with reason 5031 - add on code without appropriate primary procedure. The Plan states per the submitted claim the Type II add-on code 88334 was not billed with an appropriate primary procedure code.  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 service have not been met. As the CPT code 88334-26 was billed without an appropriate primary code and not performed by the same practitioner on the same date of service; we find that Medicare rule for payment for CPT codes 88334 26 has not been met. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan will accept a submission of a corrected claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), each additional site (List separately in addition to code for primary procedure) (CPT code 88334) provided to the enrollee on May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided February 16, 2021  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  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 code 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640 and 87798 is not supported in the medical record. Specifically, the place of service listed on the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided February 16, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on February 3, 2021 and billed
under codes D0150 and D0210.
You asked the Plan to pay for these services. You say that these dental services should be covered by the Plan.
The Plan denied your request. Maximus overturned the Plans denial. The Plan requested a reopen and provided
additional information. The Plan states it has been determined this claim denied because the benefits for
this service has been previously paid. The Plan contract states one comprehensive oral evaluation (D0150) is
allowed every three years and one full mouth x -ray (D0210) is allowed once every five years. The Plan
provided records to show these services were previously exhausted prior to February 3, 2021 on March 11,
2019.
The Plan is correct in this case. 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 more than Medicare coverage, the services provided were not available
on the dates of service in question. Therefore, we decided that the Plan does not have to pay for dental services
provided on February 3, 2021 and billed under codes D0150 and D0210.
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to pay for ambulance transport provided on November 30, 2020.
You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and provided additional information. The Plan states that this claim denied because the
claim was not billed with the ambulance pick -up and drop-off information for payment consideration. The
Medicare billing guidelines state charges for mileage must be based on loaded mileage only, which is from the
pickup of a patient to the arrival at destination.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this
case, this claim was submitted with insufficient pick-up and drop-off information. Medicare rules for coverage
of this transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance
transport provided to the enrollee on November 30, 2020.
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 you need to be transferred to an LTACH. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The records do not show that you require services than can only be provided in a hospital setting. The necessary care can safely be provided in the current acute care facility or in a skilled nursing facility.  

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 there is no documentation provided indicating medical necessity for LTACH services. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis. 

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.