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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 you do not have documented skilled nursing
needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a
maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can
be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2750).
You asked the Plan to pre-approve this item. You say that a porcelain crown is medically necessary. The Plan denied your request. The Plan says that a porcelain crown is not medically necessary.
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 this item. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that an appeal is being made for the denial of coverage for a crown restoration for tooth #30. The reason for the denial was that the service is not medically reasonable nor necessary. The documentation provided was not complete; radiographs were not included. Therefore, we are unable to determine if criteria for coverage was met due to inadequate documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2750).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve high-intensity focused ultrasound (HIFU) ablation of the prostate gland.

You asked the Plan to pre-approve the HIFU treatment. You say that this should be covered. The Plan denied your request. The Plan says that the Medicare Local Coverage Determination (LCD) L38262 states that this treatment is only covered when used as salvage therapy after recurrence post-radiation treatment.

Please note: It is Maximus' position that the LCD L38262 is not applicable to coverage of this procedure as first-line treatment. We have reviewed the Response to Comments associated with this LCD (A57835). In this document, the manufacturer notes that the scope of the LCD should be limited to salvage treatment only and that claims for primary treatment should be given individual consideration. It is noted that the Medicare Administrative Contractor agrees. There are no existing coverage determinations which disallow coverage of HIFU for primary treatment of prostate cancer. As such, Maximus has applied the Social Security Act, Section 1862 rules for medical necessity.

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 HIFU treatment. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found HIFU is a medically acceptable treatment option for stage T1c prostate cancer. High Intensity Focused Ultrasound (HIFU) treatment of the prostate is neither experimental nor investigational. HIFU was FDA approved for prostate gland ablation October 9, 2015. Numerous clinical studies have demonstrated treatment efficacy that is comparable to surgery or radiation but with a much lower risk of side effects such as impotence, incontinence and bowel injury. 

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 HIFU treatment have been met. Therefore, we decided that the Plan has to pre-approve high-intensity focused ultrasound (HIFU) ablation of the prostate gland.

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 pre-approve an Intracept procedure.

You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure remains experimental. More research is needed to show safety and efficacy of the procedure to treat back pain. 

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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing and supplies rendered on April 5, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately payable when furnished in different payment localities.
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different payment localities for billed procedure codes 95870-TC (needle electromyography) and 95938-TC (somatosensory testing). The rules say that procedure codes with a status indicator of P are bundled/excluded codes. There are no RVUs and no payment amounts for these services. Billed procedure code A45557 (lead wires) has a status indicator of P and no separate Medicare payment. 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 pay for the testing and supplies rendered on April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand finger orthosis (CPT code L3807-GZ) provided to the enrollee on January 22, 2021.

You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed.

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 orthosis have not been met. The provider did not bill as required by Medicare coding regulations. Per the Medicare guidelines, when a GZ modifier is submitted a complex medical review is not performed and the claim is automatically denied. Therefore, we find the Medicare rule of payment on CPT code L3807-GZ for this January 22, 2021, claim has not been met. Therefore, we decided that the Plan does not have to pay for the wrist hand finger orthosis (CPT code L3807-GZ) provided to the enrollee on January 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the insulin purchased from January 18, 2020, through December 26, 2020.

You asked the Plan to provide reimbursement for the insulin purchases. You say that you feel these costs should be reimbursed. The Plan denied your request. The Plan says all supplies were approved for reimbursement; however, insulin is not covered by Medicare Part B when it is not used through a pump.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to provide reimbursement for the insulin purchased from January 18, 2020, through December 26, 2020.

Benefits for the insulin purchases may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra 5% ophthalmic drops.
You asked the Plan to pre-approve Xiidra 5% ophthalmic drops. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra 5% ophthalmic drops.
Benefits for Xiidra 5% ophthalmic drops may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown repair rendered on May 25, 2021.
You asked the Plan to pay for these services. You say that the contract does not explain what type of crown is covered. The Plan denied your request. The Plan says the services are not a covered 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 crown repair rendered on May 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment (CPT code 22216) provided to the enrollee on March 15, 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 MUE is 6 and they are billing a total of 13 units on the codes 22216. The Plan states additionally billing does not match assistant surgeon 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. The code was denied per Medicare's Medically Unlikely Edits as the units billed for procedure code 22216 exceeds the allowed number of units of 6 in 1 day. Additionally, based on the medical records received the procedures and modifiers were not billed correctly for a co-surgeon. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment (CPT code 22216) provided to the enrollee on March 15, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten additional physical therapy (PT) visits.
You asked the Plan to pre-approve additional PT. You say that the enrollee requires additional physical therapy services. The Plan denied your request. The Plan says additional physical therapy is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional PT. Our reviewer says that
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy for the knee and shoulders and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, or that the services can only be safely and effectively performed by a therapist or under the supervision of a therapist. The enrollee has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program and do not require the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT have not been met. Therefore, we decided that the Plan does not have to pre-approve ten additional physical therapy (PT) visits
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for hemodialysis services provided from February 2, 2021, through April 29, 2021.

You asked the Plan to waive the coinsurance for hemodialysis services. You say that that the amounts are different each month. You also say that the cost is too expensive. The Plan denied your request. The Plan says you have been asked to pay the correct cost sharing 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 20% coinsurance for outpatient renal dialysis services. 

You have been asked to pay 20% of the allowed amount for coinsurance for hemodialysis services. The record shows you owe the following:

Hemodialysis services falls within the Services to Treat Kidney Disease 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 hemodialysis services provided from February 2, 2021, through April 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from August 21, 2020,
through August 28, 2020.
You asked the Plan to pay for the home health services. You say that this was billed in accordance with
Medicare guidelines. The Plan denied your request. The Plan says code G0153 is reported in the incorrect
revenue code.
The Plan must follow Medicare rules. Medicare rules say that all services provided must be reported on the HH
PPS claim. Revenue code ranges 044X is for reporting speech therapy services.
In this case, you billed a speech therapy visit of one hour on August 28, 2020, but this was included in the
physical therapy revenue code 0421, not in 044X. Therefore, we decided that the Plan does not have to pay for
the home health services provided from August 21, 2020, through August 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test represented by code G0483 provided on February 8, 2021.

You asked the Plan to pay for the drug test. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the drug test represented by code G0483 provided on February 8, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for an ultrasound provided on March 24, 2021.

You asked the Plan to reduce the copayment for an ultrasound. You say that that you owe a smaller copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost sharing 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 $125 copayment for radiological diagnostic services.

You have been asked to pay the allowed amount of $119.23, which is less than the $125 copayment for an ultrasound. An ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and 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 reduce the copayment for an ultrasound provided on March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the wheelchair rental provided from January
6, 2021, to May 6, 2021.

You asked the Plan to waive the deductible for the wheelchair rental. You say that you are not sure why this
wheelchair was rented as the enrollee already had a wheelchair. The Plan denied your request. The Plan says
this deductible was charged correctly.

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 $192 deductible that applies to durable medical equipment.

Records show that the wheelchair rental was applied to the member's deductible. The Evidence of Coverage
states that this deductible applies to durable medical equipmentThis 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 deductible for the wheelchair rental provided from January 6, 2021, to May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on March 15, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of P are bundled/excluded codes. There are no RVUs and no payment amounts for these services, a status indicator of I represents a code that is not valid for Medicare purposes, and payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure code A4550 (surgical trays) and 99072 (additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease) have a status indicator of B and no separate Medicare payment. Codes A4556 (electrodes, pair), A4557 (lead wires, pair), and A4649 (surgical supplies, miscellaneous) have a status indicator of P and no separate Medicare payment. Codes S1015 (intravenous tubing extension set) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes.
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 pay for the supplies rendered on March 15, 2021.