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

We decided that the Plan does not have to pay for the frames (V2020) and lenses (V2100) and miscellaneous vision service (V2799) provided November 15, 2019You asked the Plan to pay for the vision services. You say that you have your history for vision and eyeglasses with the provider for many years and it is the closest optical to your home where you can easily manage and comfortably seek care.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. Non-emergent services with non-contracted providers require prior-authorization prior to services being rendered. The plan has confirmed that there are 7 in network optical centers in the area.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 provided by an in-network provider.We looked at the file and the Plan's rules. Enrollee's must receive their medical services from an in-network provider. Non-emergent services with non-contracted providers require prior-authorization prior to services being rendered. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.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. The Plan did not pre-approve the item/service at issue. Therefore, we decided that the Plan does not have to pay for the frames (V2020) and lenses (V2100) and miscellaneous vision service (V2799) provided November 15, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 you were medically stable, with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. Functionally, given your current level, you do not require the IRF level of therapy. You may benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not medically necessary based on your current functional status and medical stability. There is a lack of complexity 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.
You asked the Plan to pre-approve Eliquis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 Eliquis.
Benefits for Eliquis 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a flexible colonoscopy (CPT 45380) provided to the enrollee
on April 2, 2019.
You asked the Plan to pay for the colonoscopy. You say that this should be paid for. The Plan denied your
request. The Plan says CPT 45380 is not supported by the medical records submitted.
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 45380 is "flexible colonoscopy, with single or multiple
biopsy."
We asked our coding 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 colonoscopy. Our reviewer says that the
services at issue in this case were not supported by the medical records submitted. Our coding reviewer found
the medical records provided do not include documentation of a flexible colonoscopy, with single or multiple
biopsy being performed on April 2, 2019, therefore this service cannot be verified.
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 colonoscopy have not been met. Therefore, we decided that the Plan does
not have to pay for a flexible colonoscopy (CPT 45380) provided to the enrollee on April 2, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency transportation.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the available clinical notes do not indicate that you are wheelchair bound, or unable to safely stand and pivot transfer into a private vehicle.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergency transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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. The patient is medically stable with no evidence of need for supervision by physical medicine and rehab Physician or need for acute rehab nursing care. Functionally though she requires physical therapy (PT) and occupational therapy (OT) she does not require IRF level of therapies. The patient may benefit from further PT and OT but does not require an IRF admission. IRF admission is not medically necessary based on the patient's current functional tolerance and lack of medical intensity. Our physician reviewer foundthat the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for insulin for administration through a pump on January 28, 2020.
You asked the Plan to waive the coinsurance for insulin. You say that you were originally told that this would be provided at no cost to you, and you administer this drug yourself with no assistance. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for insulin. Although you may be able to administer this drug yourself, it is classified as a Medicare Part B drug and therefore the Part B drug coinsurance applies to this claim. The allowed amount of the claim is $3,394, resulting in a coinsurance obligation of $678.80. You have been asked to pay 20% coinsurance for insulin. Insulin falls within the Medicare Part B Prescription 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 insulin for administration through a pump on January 28, 2020.
Your complaint regarding receiving inaccurate information about the cost-share for this drug is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe surgical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe surgical services. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are equally qualified in-network providers available to you that can provide the surgical services you are requesting.Medicare rules saythat 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-approvethe surgical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for two units of CPT 99202 provided on January 22, 2020.You asked the Plan to pay for CPT 99202. The Plan denied your request. The Plan says only one unit of this service is payable.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT code 99202 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of CPT 99202 have not been met.Therefore, we decided that the Plan does not have to pay for two units of CPT 99202 provided on January 22, 2020.
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 you cannot move around on your own. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 services are not medically necessary. Our physician reviewer found the records show that you were admitted to the hospital with sepsis due to COVID. You are now medically stable and are improving. You need mostly minimal assistance for care. You do not have any complex medical, nursing, or rehabilitation needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy but do not require an intensive therapy program 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, scaling in presence of
generalized moderate or severe gingival inflammation, adjunctive pre-diagnostic test that aids in detection of
mucosal abnormalities, complete series of intraoral x-rays, and drugs or medicaments dispensed in the office
for home use provided on January 14, 2020 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation, scaling, adjunctive pre-diagnostic test,
complete series of intraoral x-rays, and drugs or medicaments. You say that this claim needs to be appealed.
The Plan denied your request. The Plan says the treating provider is not a part of the Plan's network. The Plan
also says that no benefits are available for procedures performed by out-of-network providers or outside of the
providers contracted period.
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
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation, scaling in presence of generalized moderate or severe gingival inflammation,
adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities, complete series of intraoral xrays,
and drugs or medicaments dispensed in the office for home use provided on January 14, 2020 by an OON
provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 24, 2020 by a non-network provider.
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 were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on February 24, 2020 by a non-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the provisional splinting provided on February 13, 2020.
You asked the Plan to pay for the provisional splinting. You say that you were informed insurance would cover it. The Plan denied your request. The Plan says the claims processed correctly.
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 provisional splinting provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a nerve conduction study (CPT 95909) provided to the enrollee on January 22, 2020.
You asked the Plan to pay for the study. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 95909 remains 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 CPT code 95909 is "nerve conduction studies; 5-6 studies." 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 study. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the documentation did not include description of nerve conduction studies, 5-6 studies in report. The code cannot be verified. 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 study have not been met. Therefore, we decided that the Plan does not have to pay for a nerve conduction study (CPT 95909) provided to the enrollee on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9374) provided on June 21, 2019.You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT code S9374 has a status indicator of I which is not valid for Medicare purposes.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 S9374 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9374 has a status indicator of I. This means that CPT code S9374 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9374) provided on June 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy provided on October 14, 2019.
You asked the Plan to pay for the endodontic therapy. You say that you needed endodontic therapy because you fell and broke your jaw. You also say that you had a buccal cusp sheared off of tooth #4. The Plan denied your request. The Plan says this service is not covered under the Plan.
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 endodontic therapy provided on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 20, 2020 by a non-participating provider.
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 were rendered by a non-participating provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on February 20, 2020 by a non-participating provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 61781) provided to the enrollee.
You asked the Plan to pay for the services. You say that all of the codes were necessary for the procedure. The Plan denied your request. The Plan says it is not appropriate to report both CPT codes 61781 and 69990 for the same surgery.
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 CPT code 61781 is "Stereotactic computer-assisted (navigational) procedure; cranial, intradural (List separately in addition to code for primary procedure). We find that CPT code 61781 is not supported in the medical record. Specifically, this code is not allowed to be billed with CPT 69990. 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 surgical services (CPT 61781) provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of root canal obstruction and cone beam CT capture and interpretation provided on February 4, 2020.
You asked the Plan to pay for the treatment of root canal obstruction and cone beam CT capture and interpretation. You say that these services were provided during an emergency visit due to a toothache. You also say that you are on a fixed income. The Plan denied your request. The Plan says these services are not covered.
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 treatment of root canal obstruction and cone beam CT capture and interpretation provided on February 4, 2020.