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

We decided that the Plan does not have to pre-approve the SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that it is medically necessary for you to be admitted in the facility due to being at high risk of falls and being unable to walk and stand safely. The Plan denied your request. The Plan says you require no nursing services which would be considered skilled services by Medicare.
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 the SNF admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that requires the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that requires the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction you had on February 2, 2021.

You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says this is not a covered
benefit.

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 during a routine exam.

We looked at the file and the Plan's rules. The records show that the requested eye refraction was provided
during a medical exam and not a routine vision exam. Based on this information, we decided that the Plan's
rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay
for the eye refraction you had on February 2, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (99284) provided January 9, 2021.

You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.

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 $120 copayment for Emergency Care.

You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls within the Emergency Care 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 an emergency room visit (99284) provided January 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery
(Current Procedural Terminology (CPT) code 22869 and 22870), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the services are medically necessary. The Plan
denied your request. The Plan says the Medicare criteria for reasonable and necessary are not met as it has not
been shown to be safe and effective in long term studies and there is a lack of evidence to support that
interspinous spacer devices are as safe and effective as the gold standard of decompression.

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 surgery. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the
device.

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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex superion device placement surgery (Current Procedural Terminology (CPT) code 22869 and 22870), for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for five (5) psychotherapy visits (90834) provided on October 14, 2020, to December 2, 2020.

You asked the Plan to waive the co-payment for psychotherapy visits. You say that you received a notice from the Plan stating that your co-payments for mental health care would be taken cared of for 2020. The Plan denied your request. The Plan says the co-payment 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 co-payment for outpatient mental health care.

You have been asked to pay a $40 co-payment for each psychotherapy visit. The EOC confirms that $40 is the required co-payment for this service. The records show that you had five (5) psychotherapy visits for a total cost share of $200 ($40 x 5 visits = $200). The records also show that the cost share waiver offered by the Plan was active only through September 30, 2020. Psychotherapy visits fall within the outpatient mental health care 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 co-payment for five (5) psychotherapy visits (90834) provided on October 14, 2020, to December 2, 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 the complexity of your nursing, medical and
rehabilitation needs does not require an acute hospital inpatient s+M33on program. Medically necessary
services can be provided in a different level of care. There is not a reasonable expectation that you will be able
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. The
Plan denied your request. The Plan says the stay is 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 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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
surgical repair of a hip fracture after a fall and has been discharged home from an inpatient rehabilitation facility. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the records do not show the required conditions for approval of admission to an IRF.

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. Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care.

Our physician reviewer also found that 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 the acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does
not have a need for restorative therapies or other skilled needs.
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 physician reviewer
found that at the time of discharge from the hospital the enrollee was medically stable. She does not require any
skilled nursing or rehab services on a daily basis at an inpatient level of care. She does not require skilled
therapy to establish a safe and effective maintenance program. She does not have any parental medication,
complex wound care or nutrition given via a feeding tube. Her physical function was at or near her new
baseline. As a practical matter, she does not require any skilled services on an inpatient basis, at a SNF 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the services provided. You say that the previous claim was paid. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 30, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says that custodial care is not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The plan has not substantiated their denial in this case. The case file makes it
clear that the plan had access to medical records in making their decision to deny this admission. There were no
medical records provided to MAXIMUS for review in this case. Therefore, we decided that the Plan has to preapprove
admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee can be expected to benefit from and improve with LTACH services. The Plan denied your request. The Plan says the requested service is not medically necessary.
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 necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. Our reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer also found that the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for application of skin substitute graft to face (CPT code 15275) and
application of skin substitute graft to face (CPT code 15276 x2) provided to the enrollee on December 30,
2020.
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 that the services are not supported by the records.
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 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 services. Our physician reviewer found the record indicates that the enrollee had a
diabetic foot ulcer. The record indicates that the enrollee underwent debridement followed by placement of a
skin substitute graft that was secured with multi-layer dressing. The elements of the coverage rule re satisfied.
The requested service is recommended.
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 services have been met. Therefore, we decided that the Plan has to pay for
application of skin substitute graft to face (CPT code 15275) and application of skin substitute graft to face
(CPT code 15276 x2) provided to the enrollee on December 30, 2020.
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 pay for the office visit provided on October 22, 2019.

You asked the Plan to pay for the services provided. You say that you originally submitted the claim within timely filing guidelines. The Plan denied your request. The Plan says the corrected claim was received past the allowed timeframe.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a clean claim for the services at issue was not filed until January 22, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the office visit provided on October 22, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance services provided to the enrollee on November 30, 2020.
You asked the Plan to pay for the services. You say that this was billed correctly. The Plan denied your request.
The Plan says that this was not billed with a valid pickup zip code.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan has not substantiated their denial. You are claiming that a correct zip
code was billed on lines 39 and 80 of the claim. The Plan has not provided the claim for review in this case, so
the Plan has not substantiated their denial. Therefore, we decided that the Plan has to pay for ambulance
services provided to the enrollee on November 30, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 the enrollee was admitted for hypoxic respiratory failure due to COVID-19 pneumonia. The enrollee continues to be hypoxic and receive acute care services that have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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.