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

We decided that the Plan does not have to pre-approve interlaminar epidural steroid injections (62323).
You asked the Plan to pre-approve interlaminar epidural steroid injections. 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 follows Medicare rules. Medicare rules say that epidural steroid injections are not covered under certain circumstances. 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 interlaminar epidural steroid injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found the interlaminar epidural steroid injection is not medically reasonable or necessary. There is no role for a series of epidural steroid injections. Each injection must be evaluated for effectiveness before proceeding to another injection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of interlaminar epidural steroid injections have not been met. Therefore, we decided that the Plan does not have to pre-approve interlaminar epidural steroid injections (62323).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transportation services provided on December 8, 2020.
You asked the Plan to waive the copay for the transportation services. You say that the government waived copays. The Plan denied your request. The Plan says the claim processed 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). Your contract with the Plan clearly says that you must pay a $225 copay for ambulance services. You have been asked to pay a $225 copay for the transportation services. The services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the ambulance transportation services provided on December 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 18, 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, a cardiovascular risk assessment panel, 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 the laboratory services rendered on January 18, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for sleep studies (95810) provided March 15, 
2021 to April 21, 2021. 
 
You asked the Plan to waive the copayments for the sleep studies. You say that the copayment for the sleep 
studies should be waived. The Plan denied your request. The Plan says the claims were processed properly. 
 
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 $200 
copayment per study for Facility-based sleep studies.  
 
You have been asked to pay a $200 copayment per study for 2 sleep studies. The sleep studies fall within the 
Facility-based sleep studies 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 copayments for sleep 
studies (95810) provided March 15, 2021 to April 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 10, 2020.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214, 93000) provided March 11, 2021. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered. The Plan denied 
your request. The Plan says the deductible was not met at the time the services were provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $390 deductible for office visits.  
 
The item or service you asked the Plan to pay for falls within the benefit category office visits. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $390 deductible for office visits. 
This cost sharing is a contractual obligation that had not been met at the time the office visit was received on 
March 11, 2021. Therefore, we decided that the Plan does not have to pay for an office visit (99214, 93000) 
provided March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RFA of the SI joint.

You asked the Plan to pre-approve the RFA of the SI joint. You say that you would like reconsideration because you get injections every two weeks and are still in extreme pain. The Plan denied your request. The Plan says the requested service is considered experimental.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the RFA of the SI joint. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational. 

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 RFA of the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve RFA of the SI joint.
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 LTACH admission is medically necessary The Plan denied your request. The Plan says the enrollee's needs could be managed at a lower level of care such as a skilled nursing facility and this request cannot be approved.

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 in this case the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided from October 29, 2019,
through November 7, 2019.
You asked the Plan to pay for the acupuncture services. The Plan denied your request. The Plan says
acupuncture is not covered by Medicare. In addition, the member's 2019 plan did not offer a supplemental
benefit for acupuncture.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have
to pay for acupuncture services provided from October 29, 2019, through November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on February 4, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider does not participate in Medicare.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the services you received on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wellness visit provided on March 31, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the wellness visit. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 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 wellness visit provided on March 31, 2021 by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided on
January 13, 2021.

You asked the Plan to waive the copayment for the vision services. You say that you are being billed by a
physician that did not perform the surgery or the post-operative service. The Plan denied your request. The Plan
says the correct copayment has been applied to the claim. Also, you still owe a $40 copayment from the
physician's services provided in November 2020.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for vision care.

You have been asked to pay a $40 copayment for the vision services. The vision service falls within the vision
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 vision services provided on January 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit, and inpatient hospital services provided February 16, 2020 to February 19, 2020.
You asked the Plan to waive the copayment for the emergency room visit and inpatient hospital services. You say that the copayment should be waived as you already paid the provider. 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 $90 copayment for Emergency Care and a $360 per day copayment for inpatient care.
You have been asked to pay a $1,170 copayment for 3 days of inpatient care ($360 a day) and an emergency room visit ($90). 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, and inpatient hospital services provided February 16, 2020 to February 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 3rd facet joint injection.

You asked the Plan to pre-approve a 3rd facet joint injection. 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 follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered medically reasonable and necessary when specific criteria are met. 

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 a 3rd facet joint injection. Our reviewer says that the services are not medically necessary. Our physician reviewer found the guidelines state only 2 levels can be treated at a time on one side or both sides of the spine. Medical necessity has not been met for a third injection at the same time. The review has determined that you do not meet the coverage criteria. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a 3rd facet joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a 3rd facet joint injection.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray (73610) provided March 1, 2021.
You asked the Plan to waive the copayment for the x-ray. You say that this was a post-operative exam and the copayment should be waived. The Plan denied your request. The Plan says the correct copayment 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 $195 copayment for outpatient radiology services. You have been asked to pay the Medicare allowable amount of $83.48 for the x-ray. The x-ray falls within the outpatient radiology services benefit category. The Medicare allowable amount is less than the $195 copayment listed in the plan contract. 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 x-ray (73610) provided March 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health services provided to the enrollee September
11, 2020, to September 12, 2020.
You asked the Plan to pay for this claim as billed. You say that these services should be covered by the Plan.
The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the
Plans denial stating the services provided were medically necessary. The Plan requested a reopen and stated
that the issue was not medical necessary but that the claim was submitted with errors. The Plan states that the
providers submitted their claim with a medical diagnosis, which was incorrect as the services rendered were
psychiatric hospital care. Therefore, the claim must be submitted with psychiatric diagnosis codes. The Plan
states they requested a corrected claim as they are unable to approve the claim if an incorrect diagnosis is
billed. The Plan states once a corrected claim is received with updated diagnosis codes, it can be reviewed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. While it is understood the
enrollee was being seen for a medical emergency, and not a mental health episode, the diagnosis codes for any
type of mental evaluation must be reported appropriately. Medicare rules for coverage of this claim as billed
have not been met. Therefore, we decided that the Plan does not have to pay for mental health services
provided to the enrollee September 11, 2020, to September 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve eight (8) additional PT visits. You say that additional PT visits are 
medically necessary. The Plan denied your request. The Plan says eight (8) additional PT visits are 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 eight (8) additional PT visits. 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 that in this case, you have previously been treated 
with outpatient therapies and should be independent with a home exercise program. There is no documentation 
of a recent injury or decline in function. The additional therapy services are not an appropriate duration and 
frequency for treatment of your medical condition and therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of eight (8) additional PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve eight (8) additional PT visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eleven (11) additional PT visits.
You asked the Plan to pre-approve eleven (11) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says an additional eleven (11) physical therapy visits does not meet medical necessity criteria under Medicare.
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 eleven (11) additional PT visits. 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 that in this case, the enrollee has previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical condition and therefore are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of eleven (11) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eleven (11) additional PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the lift chair rendered by the out-of-network (OON) provider on March 10, 2021.

You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the item was rendered by an out of 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at issue.

We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to issue reimbursement for the lift chair rendered by the out-of-network (OON) provider on March 10, 2021.