Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe visit you had to the Cancer Center at THE Hospital on March 4, 2020.You asked the Plan to waive the copayment forthe specialty visit. You say that follow-up visits within 90 days of your surgery shouldn't have a copayment.The Plan denied your request. The Plan says you were charged this copayment 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 $35 copayment for specialist visits. Records show that you had surgery at THE Hospital on February 21, 2020. Although the visit at issue on March 4, 2020 is within 90 days of the surgery, this visit was performed by a different billing provider (. THE Hospital).  Because these are different billing providers, the 90-day post-surgical period does not apply to follow up visits. You have been asked to pay a $35 copayment for the specialty visit. The specialty visit falls withinthe specialist visits 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 forthe visit you had to the  Cancer Center at THE Hospital on March 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea sleep study to be provided by an out of network (OON) provider.In-network providers are available for these services.You asked the Plan to pre-approvea sleep study. You say that there are in-network providers available.The Plan denied your request. The Plan says there are in-network providers available.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 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-approvea sleep study to be provided by an out of network (OON) provider.In-network providers are available for these services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay fornon-emergent ambulance transport provided to the enrollee.You asked the Plan to pay forambulance transport for physician follow-up. You state that CMS expanded the rules for ambulance transport to a physician'sappointment due to Covid-19 and this transport should be covered. The Plan denied payment. Maximus upheld the Plans denial. You requested a reopen and stated this transport should be covered because of the restrictions for transport lifted by CMS due to Covid-19. Our Medical Director looked the case file and the reopen request. Our physician reviewer found that the allowed ambulance transports during COVID-19had been temporarily expanded to include physician's offices. However, the medical criteria for those transports being necessary was not altered by CMS. The medical records show the ambulance was dispatched to the THE HOME for transport to the hospital for a follow-up appointment. The enrollee said she couldn't walk anymore. Bilateral weakness was noted in the lower extremities. The rules say that ambulance services are only covered when the patient's clinical condition is such that other methods of transport are contraindicated. However, the documentation provided does not support that other means of transport were contraindicated for thisenrollee on the date of service. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equippedambulance can provide for safe transport. Finally, the documentation does not support that ambulance transport was medically reasonable and necessary for the enrollee. Since the transport itself was not necessary, the Covid-19 exception does not apply. Medicare criteria for ambulance transport were not met. We looked at this physician's review, the file, the Plan contract and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergent ambulance transport were not met. In addition, the enrollee did not have prior authorization for this transport. We found no exception that would require our original decision to change. Therefore, we decided that the Plan does not have to pay fornon-emergent ambulance transport provided to the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveambulance services.You asked the Plan to pre-approvethe ambulance services. You say that the enrollee has bilateral leg weakness and was found to have acute kidney injury/chronic kidney disease. You say that the enrollee needs a stretcher with oxygen transportation for his discharge to a rehabilitation facility.The Plan denied your request. The Plan says the clinical information provided does not support the medicalnecessity for ambulance transportation services.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance services. Our reviewer says that the criteria for coverage of ambulance transportation services have not been met. Our physician reviewer found the enrollee came to the emergency department on February 13, 2021, as he had been getting shaky when he walks and almost falls down. The records show that the enrollee physically did not hit his head and did not have any active complaint. In the emergency department, he was vitally stable not requiring any oxygen, blood pressure was normal. He was found to have acute kidney injury/chronic kidney disease with a creatinine of 1.5. He was evaluated and seen by physical therapy.  Physical Therapy notes from February 13, 2021 show that the enrollee was an alert and oriented to person, was able to follow simple commands, lives alone on a 6th floor apartment with elevator, owns a single point cane and rolling walker. The physical therapy exam results show that the enrollee was 3+/5 on bilateral upper and lower extremities. The enrollee demonstrated fair minus grade with static/dynamic standing balance with minimal/contact guard assist and using a rolling walker. The enrollee ambulated short distance, including 5 feet with very short step length and with minimal assist and a rolling walker. Gait quality appeared unsteady. He was transported. The documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee. The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance could provide for safe transport. The documentation did not support that the ambulance transport being requested is medically reasonable or necessary for the enrollee.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 ambulance services have not been met.Therefore, we decided that the Plan does not have to pre-approveambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal adjustment (D9951).

You asked the Plan to pay for the occlusal adjustment. You say that since this service was provided all of your teeth mesh. The Plan denied your request. The Plan says this service is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal adjustment (D9951).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator (63650).

You asked the Plan to pre-approve a neurostimulator. You say that this device is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for the requested device are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.

Our Medical Director looked at the case file and the reopen request. Our Medical Director says at issue is coverage for a type of neurostimulator. The Maximus Physician Reviewer determined that the request was for a stimulator exchange, not a new placement. The Plan argues that the records do not show that you have tried physical, psychological, or surgical therapies, nor was there evidence that you had undergone careful screening, evaluation, and diagnosis by a multidisciplinary team prior to implantation of a spinal cord stimulator. Our Medical Director looked at the medical records. You have a diagnosis of lumbar radiculopathy. You had a peripheral nerve stimulator. A dorsal column stimulator trial and removal of the peripheral nerve system were recommended. It was documented that you have been using a spinal cord stimulator but still having significant pain. An epidural injection was administered. A spinal cord stimulator trial was ordered. Our Medical Director has concluded that the Plan is correct in this case. The medical record documentation does not support that the coverage criteria for spinal cord stimulation as established by LCD L35450 are met.

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 neurostimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator (63650).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee has no support due to her husband's dementia and is requesting 24-hour assistance. The Plan denied your request. The Plan says SNF care is not supported based on the records received. The Plan says that the services required can be safely received at a different setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 services. 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. She 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. She is medically stable. Her physical function is at or near her baseline and she 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
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 records provided support the need for IRF care. The Plan denied your request. The Plan says the enrollee does not meet medical necessity for 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 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical treatment of a hip fracture after a fall. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Part B drug or the office visit provided
on September 2, 2020.
You asked the Plan to waive the cost share for the Part B drug and the office visit. You say that you cannot
afford this bill. The Plan denied your request. The Plan says you have been charged the correct cost sharing
amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare Part B covered drugs in an in-network primary care physician's office and a $10
copayment provider and professional services in an in-network primary care physician's office.
You have been asked to pay $15.47 which is less than the standard 20% of the allowed amount for the Part B
drug. The allowed amount is $133.54. You have also been asked to pay a $5.20 copayment, which is less than
the standard amount, for the office visit. The Part B drug falls within the "Medicare Part B prescription drugs"
benefit category. The office visit falls within the "Physician/Practitioner services, including doctor's office
visits" benefit category.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 73610) provided to the enrollee on September 3, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says anatomic-specific modifiers are required whenever they are appropriate to further clarify where the service was performed.
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 73610 is "Radiologic examination, ankle." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found CPT 73610 refers to examination of ankle. Therefore, when billing this procedure an anatomic modifier should be reported with this procedure to identify which (or both) ankle(s) was examined. Modifier LT, RT or 50 (bilateral) would be reported. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (CPT 73610) provided to the enrollee on September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal provided on January 21, 2020.
You asked the Plan to pay for the dental service. You say that you were referred to this provider for a molar
abscess. You say that he scheduled you for a root canal. You say that you were informed there would be a
copayment of $472.50. You say that you received a bill for $1,370. You also say that the service should be
covered because you were under the care of the same provider. The Plan denied your request. The Plan says
root canal is not listed as a covered service.
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 root
canal provided on January 21, 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 IRF care is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for COVID-19 pneumonia and pulmonary embolism. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services.

You asked the Plan to pay for the acupuncture services. The Plan denied your request. The Plan says the coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the documentation shows that the acupuncture services were provided for a diagnosis of hip pain. Acupuncture is not covered for hip pain. Therefore, we decided that the Plan does not have to pay for the acupuncture services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 20, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the laboratory services. 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 laboratory services provided on December 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance transport services.

You asked the Plan to pay for the services provided. You say that the claim was paid at a very low compensation. The Plan denied your request. The Plan says the claim was processed correctly.

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.

We looked at the file, and Medicare rules. The medical records show that the enrollee was transferred to a facility for services that were not available at the originating facility. The records do not show that the enrollee's medical condition needed immediate and rapid ambulance transport that could not have been provided by ground ambulance. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to further pay for the air ambulance transport services.