Persius/hicric huggingface dataset:
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 enrollee needs IRF services. The Plan denied your request. The Plan says the enrollee can get therapy a a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient 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 long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you need LTACH to regain maximum function. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

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 you are receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition at this time.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and duplex scan provided by an out-of-network provider on August 19, 2020.
You asked the Plan to pay for the office visit and duplex scan. You say that you attached medical notes for further review and are requesting an appeal for the denied claim. The Plan denied your request. The Plan says care received from a non-network provider will not be covered.
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 office visit and duplex scan provided by an out-of-network provider on August 19, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound provided to the enrollee on June 22, 2020 and billed under Claim A.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan stated that Claim A denied because the plan had already paid for this service under another claim. The Plan states the NPI website shows that both providers are listed as Diagnostic Radiology Specialists and both providers work within the same professional practice or group. The Plan states the correct billing of this service needed to include modifier 59 to establish a separate and distinct service was provided.

The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for Claim A as billed.
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 enrollee requires a higher level of care for pain management and for an intensive therapy program. The Plan denied your request. The Plan says the enrollee is not likely to participate in three hours of therapy.
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 patient was admitted for rib fractures after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation that this patient 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. 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 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 the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. The enrollee is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. The enrollee is medically stable without any acute exacerbations of chronic medical problems. The enrollee's physical function is at or near their baseline and he can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for two electrocardiogram (EKG) interpretations and reports billed to the enrollee for July 20, 2020 under Claim A.

You asked the Plan to pay this claim. 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. The Plan requested a reopen and provided additional claim information. The Plan states this claim denied because it was previously paid under Claim B. The NPI website shows that both providers are Emergency Medicine Specialists. The Plan states a professional component billing based on a review of the findings of these procedures without a complete written report does not meet the conditions for separate payment of the service. The Plan states the review is already included in the emergency department evaluation and management (E/M) payment.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems.

Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for the interpretation billed to the enrollee for July 20, 2020 under Claim A.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a segmental pneumatic appliance (E0673) provided on August 13, 2020.

You asked the Plan to pay for a segmental pneumatic appliance. You say that the requested item is a necessity for the enrollee. The Plan denied your request. The Plan says rules for a segmental pneumatic appliance have not been met.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a segmental pneumatic appliance (E0673) provided on August 13, 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 services are medically necessary. The Plan denied your request. The Plan says 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 enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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 more for the crown (D2740) provided on January 28, 2021.
You asked the Plan to pay more for the crown. You say that you would like to appeal this service. The Plan denied your request. The Plan says your annual maximum benefit of $2,000 has been reached.
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 Plan offers a $2,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the January 28, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the crown (D2740) provided on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an adult day care program.

You asked the Plan to pre-approve adult day care program. You say that the enrollee really needs this service. The Plan denied your request. The Plan says the denial of authorization for this adult day care program is correct, because this is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that custodial care services such as adult day care programs are not covered by Medicare. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of adult day care program have not been met. Therefore, we decided that the Plan does not have to pre-approve an adult day care program.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on August 5, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. 

The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on August 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new power wheelchair with elevating legrests, a tray table, and oxygen concentrator holder.

You asked the Plan to pre-approve the new power wheelchair. You say that you feel that you should have to right to have a brand new wheelchair covered by the Plan rather than being given a used one. The Plan denied your request. The Plan says the PACE has approved a wheelchair that will be modified to meet your needs. Also, other items can be approved to allow for better elevation of the legs, which would improve edema management.

The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status. 

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 new power wheelchair. Our reviewer says that the documentation does not support that a new, unused power wheelchair is medically necessary to meet the enrollee's needs. Our physician reviewer found the enrollee is an 83-year-old woman with a history of heart failure, asthma, chronic respiratory failure, peripheral vascular disease, type 2 diabetes with polyneuropathy, chronic kidney disease, and lower extremity edema. It is noted that the enrollee's current chair is old and can no longer be fixed if broken. 

The documentation does not support that a new power wheelchair with accessories is medically necessary and reasonable to meet the participant's needs and to improve and maintain the participant's overall health status. The option offered by the PACE, including a used power chair with modifications to elevate her legs, appear to be reasonable to meet the participant's needs at this time.

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 new power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a new power wheelchair with elevating legrests, a tray table, and oxygen concentrator holder.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on January 4, 2017, and January 5, 2017.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 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 services provided to you by an out-of-network provider on January 4, 2017, and January 5, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a microprocessor knee, advanced foot, and upgraded cover.
You asked the Plan to pre-approve a microprocessor knee, advanced foot, and upgraded cover. You say that that a microprocessor knee is indicated for you. The Plan denied your request. The Plan says Medicare criteria for the requested items are not met as the items are not reasonable and 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 a microprocessor knee, advanced foot, and upgraded cover. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the review indicates that you are status post left trans-femoral amputation from March 9, 2019; residual limb described as healthy. You are currently using a preparatory prosthesis obtained July of 2019. You are currently using a cane or crutches for ambulation, and therefore you do not appear to function at a K3 level in spite of being a full time prosthetic user since 2019. The use of cane or crutch for ambulation is not consistent with K3 ambulation. The request for a microprocessor knee and K3 foot exceeds your need and does not meet the Medicare criteria of reasonable and 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 a microprocessor knee, advanced foot, and upgraded cover have not been met. Therefore, we decided that the Plan does not have to pre-approve a microprocessor knee, advanced foot, and upgraded cover.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says rules for SNF care have 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 This patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient has no complex wound care or other SN need. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).