Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke and was transferred to a skilled nursing facility then discharged home on March 3, 2021. There is ongoing weakness since moving to the home environment. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the copayment for the wound debridement services
(11042) provided from February 4, 2020, to February 25, 2020.
You asked the Plan to waive or reduce the copayment for the wound debridement services. You say that you
feel the cost for your initial surgery was acceptable, but feel this copayment is too much for the follow-up
debridement services. You feel that this service must have been billed or coded wrong. The Plan denied your
request. The Plan says this wound care service is classified as a surgical procedure, and your copay was applied
correctly. Medical records were provided to support the bill.
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 $250
copayment for outpatient surgery and services provided at an outpatient hospital facility.
You have been asked to pay a $250 copayment for each day of wound debridement services. The wound care
services were provided in the wound care center of an outpatient hospital facility and are classified as a surgical
procedure or service. 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 or reduce the copayment for the wound
debridement services (11042) provided from February 4, 2020, to February 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (procedure code 0012M).

You asked the Plan to pay for CxBladder test. You say that you disagree with the Plan's denial of this testing.
The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this test is
experimental/investigational.

The Plan must follow Medicare rules. Medicare rules say that CxBladder testing is non-covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of CxBladder test have not been met. Therefore, we decided that the Plan does not have to pay for
CxBladder testing (procedure code 0012M).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203), x-ray exam of the foot (73630), and
the growth removal (11055) provided by an OON provider.

You asked the Plan to pay for the medical services. You say that the provider's office told you that they take
your insurance. You have also tried to get a referral from your primary care provider but have not been able to
get one. The Plan denied your request. The Plan says they do not cover out-of-network services except in
limited circumstances. These services were not urgent or pre-approved and could have been provided in-network.
No referral was provided.

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.
Therefore, we decided that the Plan does not have to pay for the office visit (99203), x-ray exam of the foot
(73630), and the growth removal (11055) provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Myriad myRisk panel rendered on December 23, 2019.
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 were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing 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 services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of family history of malignant neoplasm of breast. The case file does not contain any clinical medical records for this enrollee. Consequently it cannot be determined that all of the criteria for coverage were met or that the testing was 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the Myriad myRisk panel rendered on December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reline complete upper denture (laboratory) (D5750)
and reline complete lower denture (laboratory) (D5751).
You asked the Plan to pre-approve a reline complete upper denture and reline complete lower denture. You say
that the services are necessary. The Plan denied your request. The Plan says the requested services 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 a
reline complete upper denture (laboratory) (D5750) and reline complete lower denture (laboratory) (D5751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vision care services to be provided by an OON provider.
You asked the Plan to pre-approve vision care services. You say that you would like the Plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent
to seek out-of-network care. The Plan says there are multiple in-network specialists available to the enrollee
that can treat the enrollee's condition.
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-approve
vision care services to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammogram (99499) provided by an OON provider.

You asked the Plan to pay for the mammogram. You say that you wanted a second opinion from a previous
provider. The Plan denied your request. The Plan says you did not receive a referral and the service did not
meet OON criteria for coverage.

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.
Therefore, we decided that the Plan does not have to pay for the mammogram (99499) provided by an OON 
provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (93010 ) provided to the enrollee on June 11, 2020.
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 this claim was inappropriately billed. Maximus overturned the Plans denial. The Plan requested a reopen and stated that in this case, Medicare does not separately pay any provider or supplier other than the facility for services furnished to the beneficiary. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made between the facility and outside vendors. The enrollee received the services in preparation for treatment at a facility. Payment for this service would be included in the facility payment. The Plan states this is supported in the Code of Federal Regulations (CFR) 42 CFR 409.3 as well as the Code of Federal Regulations (CFR) 42 CFR 412.50.
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 and bill under the appropriate circumstances. In this case, payment for pre-admission diagnostic services is included in the facility payment and is not separately billable. Medicare rules for coverage of this service have not been met based on how they were billed. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (93010 ) provided to the enrollee on June 11, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove Minimed 770G pump and Guardian 3 sensor (E1399).
You asked the Plan to preapprove the blood sugar sensor. You say that you require the device. The Plan denied your request. The Plan says the device does not meet coverage criteria as it is not a therapeutic CGM because it depends on a smart phone.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee may require a CGM, but the blood sugar sensor requested is not a CGM, it is dependent on a smart phone and does not meet the definition of durable medical equipment. Based on this information, we decided that Medicare rules for coverage of the blood sugar sensor have not been met. Therefore, we decided that the Plan does not have to preapprove Minimed 770G pump and Guardian 3 sensor (E1399)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you additionally for eyeglass lenses.

You asked the Plan to reimburse you additionally for eyeglass lenses provided by an out-of-network provider. You say that progressive lenses are covered so the Plan should reimburse you $425. The Plan denied your request. The Plan says they paid the maximum allowable of $150 for the covered eyewear.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when the Plan pays up to $150 for covered eyewear from an out-of-network provider.

We looked at the file and the Plan's rules. You purchased the eye wear from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of eyeglass lenses with a $0 have not been met. Therefore, we decided that the Plan does not have to reimburse you additionally for eyeglass lenses.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 9, 2020.
You asked the Plan to pay for the physician's 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 physician's 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 physician's services provided on June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for 25 hydroxy Vitamin D testing (82306).

You asked the Plan to pay for 25 hydroxy Vitamin D testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that 25 hydroxy Vitamin D testing will be considered medically reasonable and necessary for the indicates listed in the LCD.

We looked at the file and Medicare rules. The record does not show that the enrollee had a covered indication for the testing at issue. Based on this information, we decided that Medicare rules for coverage of 25 hydroxy Vitamin D testing have not been met. Therefore, we decided that the Plan does not have to pay for 25 hydroxy Vitamin D testing (82306).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the two duplex scans.

You asked the Plan to waive the copayments for the duplex scans. You say that you are upset that your plan didn't pay more towards these services. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan also says that for one of the duplex scans you had, the allowed amount is less than your copayment obligation ($131.35). The Plan says that because of this, you are responsible for the full amount for that scan.

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 $155 copayment for each Medicare-covered radiological diagnostic service.

You have been asked to pay a $155 copayment for each of the duplex scans. The duplex scans fall within the Medicare-covered radiological diagnostic service 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 the two duplex scans.
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 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmic biometry.

You asked the Plan to waive the copayment for ophthalmic biometry. You say that you disagree with the denied charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 a $40 copayment for each specialist visit.

You have been asked to pay the allowed amount of $23.19, which is less than the $40 copayment for ophthalmic biometry. ophthalmic biometry falls within the physician/practitioner services, including doctor's office 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 for ophthalmic biometry.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the catheter insertion rendered on October 12, 2020.
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 procedure code 51702 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 15830 and 51702. Code 51702 is a column II code with a modifier indicator of 1 when billed with column I code 15830. Code 51702 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the catheter insertion rendered on October 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says this request does not meet the Plan's Part B coverage criteria for Prolia.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drug Zoledronic Acid before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. Our reviewer also found that there is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the nutritional packaged meals provided on November 26, 2020.
You asked the Plan to reimburse you for the nutritional packaged meals. You say that you were told it was a covered benefit. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to reimburse you for are nutritional supplements. Neither Medicare nor the Plan cover these items. Therefore, we decided that the Plan does not have to reimburse you for the nutritional packaged meals provided on November 26, 2020.