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

We decided that the Plan does not have to pay for a domiciliary, rest home visit.

You asked the Plan to pay for the domiciliary, rest home visit. 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 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 a domiciliary, rest home visit.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pre-approve a repeat echocardiogram with doppler for the enrollee.

You asked the Plan to pre-approve a repeat echocardiogram with doppler. You say a repeat echocardiogram with doppler is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. Our Medical Director says at issue is coverage for a repeat echocardiogram. The Maximus Physician Reviewer determined that there is some significant discrepancy in the aortic root measurements and at least some reported increase in aortic root size. For this reason, a repeat echocardiogram with good measurements of the root would be reasonable and useful to firmly re-assess aortic root size. The Plan requested a reopen and stated the enrollee had no change in her cardiac status, and that the recent echo supports that the aortic root is normal, and the measurement is normal. Our Medical Director states the medical records show the enrollee had no complaints during a routine cardiac follow-up visit. The assessment included "Dilated Ascending Aorta". A thoracic echocardiogram was a technically difficult study due to body habitus, patient being unable to cooperate, and obesity. The aortic root, ascending and descending aorta were normal. Measurements were within normal limits. Our Medical Director concluded the Plan is correct in this case. The documentation does not support that a repeat echocardiogram was medically reasonable and necessary. The enrollee was asymptomatic, and an echocardiogram did not demonstrate a dilated aorta.

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 repeat e have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat echocardiogram with doppler for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine.

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.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the shingles vaccine.

Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a wheelchair.

You asked the Plan to reimburse you for the wheelchair. You say that the in-network DME supplier's wheelchairs would cost you $300; however, the wheelchair you purchased was affordable. The Plan denied your request. The Plan says that it is important to know which providers are part of our network because, with limited exceptions, while you are a member of our Plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.

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 reimburse you for a wheelchair.
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 was independent prior to this hospitalization and needs to return to her functional mobility and the physical state she was in. The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of IRF 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 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 congestive heart failure, atrial fibrillation, gastrointestinal bleeding. 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: 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 necessary. The Plan denied your request. The Plan says based on the documentation provided, 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 above.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Confirm MDx Epigenetic Molecular Assay.

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 testing was not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that Confirm MDx testing is covered 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 pay for these services. Our reviewer says that the testing was not medically necessary. Our physician reviewer found the enrollee had elevated prostate specific antigen (PSA) and underwent needle biopsy of the prostate. It is not documented that the minimum tissue volume criteria of 20 microns of prostate biopsy core tissue was obtained. The criteria for coverage were not met; therefore, the testing is not covered.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the Confirm MDx Epigenetic Molecular Assay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone replacement grafts (D7953).

You asked the Plan to pre-approve the bone replacement grafts. You say that you are in terrible pain which gets worse daily. You say that you are unable to eat anything that isn't soft and cannot have cold beverages. The Plan denied your request. The Plan says the services in dispute are 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 pre-approve bone replacement grafts (D7953).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation services.

You asked the Plan to waive the copayment for the observation services. You say that you disagree with the amount owed. The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.

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 $50 copayment for emergency services provided in the outpatient hospital settings.

You have been asked to pay a $50 copayment for the observation services. The observation services fall within the outpatient hospital 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 copayment for the observation services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says that the services rendered are not medically
necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the enrollee presented to the emergency room after a fall at home. The enrollee's evaluation revealed a left distal radius fracture, left tibia/fibula fracture and three rib fractures. The enrollee was admitted for pain control. The enrollee was evaluated by Orthopedics and therapy services. The enrollee was discharged to a subacute rehabilitation facility when the enrollee was considered medically stable. The documentation supports that at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or
observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation services.

You asked the Plan to pay for the ambulance transportation services. You say that you would like the plan to
reconsider their decision. The Plan denied your request. The Plan says the services must be submitted to the
enrollee's work-related injury coverage.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you,
the provider to send the bill to the enrollee's work-related injury coverage providers. Therefore, we decided
that the Plan does not have to pay for the ambulance transportation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).

You asked the Plan to pre-approve a total electric hospital bed. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not covered.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that you strongly believe this admission
was appropriate, and you expect full reimbursement as the services rendered could not have been provided in
an outpatient setting. The Plan denied your request. The Plan says that services could have been provided in a
lower level of care, such as observation.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the enrollee presented to the hospital on with symptoms of body aches, vomiting,
and chills. His symptoms started earlier in the day at dialysis. He had no chest pain, but he had SOB. He was
admitted for Suspected COVID-19 infection, acute or chronic renal insufficiency, dysphagia, and respiratory
abnormality. Dialysis was continued. The COVID-19 PCR was negative the same day he was
admitted. Vancomycin and Cefepime were discontinued and he was started on Augmentin for
possible aspiration. He was discharged in stable condition. The review has determined that the
record showed that at the time of inpatient admission the admitting physician reasonably expected that the
patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam and panoramic x-rays.

You asked the Plan to pay for these services. You say that you didn't realize the services wouldn't be covered. The Plan denied your request. The Plan says services from an out-of-network provider are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers supplemental dental benefits from a participating provider only.

We looked at the file and the Plan's rules. The file shows that you received services from a non-participating provider. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral exam and panoramic x-rays.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Office or other outpatient visit for the evaluation and management of a new patient (99204) provided by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the provider was told by your supplemental health insurance that a prior authorization was not needed. The Plan denied your request. The Plan says the services were rendered by an OON provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows that you were referred to a different provider than the doctor at issue. Therefore, we decided that the Plan does not have to pay for the Office or other outpatient visit for the evaluation and management of a new patient (99204) provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings, four films (D0274).

You asked the Plan to pay for the dental services. You say that you would appreciate payment for this part of your dental visit being reconsidered and paid, per the preventive dental services covered under your plan. The Plan denied your request. The Plan says this service is not listed as covered under the plan benefits.

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. D0274 is not listed under the services that are covered, therefore this service is not covered by the plan.

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 bitewings, four films (D0274).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care.

You asked the Plan to pay for the acute inpatient level of care. You say that you have enclosed medical records to both demonstrate your compliance with the recognized standards of care and to provided evidence that the services rendered were medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet the criteria for continued inpatient stay. Continued care can be provided at a lower level.

The Plan must follow Medicare rules. The rules say that inpatient hospital services are covered if the enrollee's condition can be managed safely only in the inpatient hospital setting.

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 acute inpatient level of care. Our reviewer says that the requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted with diabetic ketoacidosis. The Health Plan approved due to severe orthostasis from volume depletion and possible autonomic dysfunction and unstable blood sugars. The review has determined that the inpatient admission was appropriate. The enrollee should not have been admitted to observation. The documentation indicates that the patient could not have been discharged from the emergency department and followed up as an outpatient.

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 acute inpatient level of care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care.

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.