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 low back pain and lumbar spinal stenosis. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle foot orthoses (L3170 and L1971) provided on October 6, 2020.
You asked the Plan to pay for the ankle foot orthoses. You say that you would like reconsideration because the orthoses are medically necessary. The Plan denied your request. The Plan says there is not evidence of an established relationship between the ordering provider and member.
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 pay for the ankle foot orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal evidence of an objective physical examination of the member indicating weakness or deformity of the foot and ankle with a need for stabilization and the
potential to benefit functionally from the requested L1971 and L3170 orthoses. 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 ankle foot orthoses have not been met. Therefore, we decided that the Plan does not have to pay for ankle foot orthoses (L3170 and L1971) provided on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services.

You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider has opted out of the Medicare program.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the physician services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital bed and manual wheelchair, for the enrollee.

You asked the Plan to pay for the DME. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says for the purposes of establishing medical necessity, and reimbursement, the CPT (Current Procedural Terminology) code(s) must be specified. The Plan states they did not receive that information and they also did not receive an order form signed by a doctor. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. CPT Codes were not provided to establish medical necessity and the Plan did not receive an order form signed by a doctor. Therefore, we decided that the Plan does not have to pay for a hospital bed and manual wheelchair, for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on July 13, 2020.
You asked the Plan to pay for the office visit. You say that authorization was not done due to an error. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 provided by an out-of-network provider on July 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound.

You asked the Plan to waive the copayment for an ultrasound. You say that you paid less in the past and disagree with the 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 $155 copayment for ultrasounds.

You have been asked to pay the allowed amount of $131.27, which is less than the $155 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an ultrasound.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.

We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness exam provided on December 1, 2020.
You asked the Plan to pay for the annual wellness exam. You say that you would like reconsideration because you were not sure when your last wellness exam was and were unable to contact your provider. The Plan denied your request. The Plan says you are allowed one annual wellness exam per calendar year.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness exam provided on December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued coverage of a Continuous Positive Air Pressure (CPAP) machine (E0562).

You asked the Plan to pre-approve continued coverage of the CPAP machine. You say that the CPAP is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

"The Plan follows Medicare rules. Medicare rules say that adherence to therapy is defined as use of PAP 4 or more hours per night on 70% of nights.

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 continued coverage of the CPAP machine. Our reviewer says that continued coverage of the CPAP machine is not medically necessary. Our physician reviewer found the records provided show that the enrollee used the CPAP over 4 hours each night 16-32% of the time. This did not demonstrate adherence to the therapy as required by coverage rules.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued coverage of the CPAP machine have not been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage of a Continuous Positive Air Pressure (CPAP) machine (E0562).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transports.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the request exceeds the benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. The file shows that you have used 17 of the total 36 one-way trips allowed by your supplemental routine transportation benefit. Once you have used all 36 one-way trips, further trips are not covered by Medicare or your supplemental benefit. Therefore, we decided that the Plan does not have to pre-approve additional routine transports.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam (92014).

You asked the Plan to waive the copayment for the eye exam. You say that you would like reconsideration because this was a plan provider and these services were denied. The Plan denied your request. The Plan says the claim applied a $10 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 $10 copayment for Vision Care.

You have been asked to pay a $10 copayment for the eye exam. The eye exam falls within the Vision Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the eye exam (92014).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the PancreasDx genetic testing panel (including the following genes: CFTR full gene sequence, PRSS1, SPINK1, CASR, CTRC, and VCF genome sequence analysis).

You asked the Plan to pay for the PancreasDx panel. You say that this is correctly coded for reporting the gene testing provided. These codes have been reimbursed by the Original Medicare contractor, and plans are required to cover what Original Medicare covers. The Plan denied your request. The Plan says the Policy Article A57880 states that for genetic panels that test multiple genes, a single code must be reported for the panel.

Maximus reviewed the Policy Article cited by the Plan. We found that this does not apply to Medicare Part B covered services provided in the State of Pennsylvania. As such, our decision was based solely on the general medical necessity rules cited in the Medicare rules section.

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 pay for the PancreasDx panel. Our reviewer says that the genetic testing panel provided is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 65-year-old woman with a diagnosis of Idiopathic acute pancreatitis with uninfected necrosis. According to the genetic counselor report, the enrollee has had two episodes of pancreatitis requiring hospitalization. There are no clinical records submitted for review. The documentation in the case file does not support that all of the genes in the PancreasDx genetic panel were medically reasonable and necessary for the enrollee in this case.

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 PancreasDx panel have not been met. Therefore, we decided that the Plan does not have to pay for the PancreasDx genetic testing panel (including the following genes: CFTR full gene sequence, PRSS1, SPINK1, CASR, CTRC, and VCF genome sequence analysis).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for continued skilled nursing facility (SNF) services.

You asked the Plan to pay for SNF care. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.

The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.

We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pay for continued skilled nursing facility (SNF) services.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI.

You asked the Plan to waive the copayment for an MRI. You say that you disagree with the charges because you were under the impression that you would owe nothing. 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 $50 copayment for MRI's.

You have been asked to pay a $50 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an MRI.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided by an out of network (OON) provider.

You asked the Plan to pay for specialist services. You say that referrals are not needed for in-network providers. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available for these services.

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 specialist services provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies.

You asked the Plan to waive the coinsurance for DME and related supplies. You say that you disagree with the 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 20% coinsurance for DME and related supplies.

You received DME and related supplies. The total allowed amount is $767.36 and 20% of that is $153.47.

You have been asked to pay the total coinsurance amount of $153.47 for DME and related supplies. DME and related supplies fall within the DME and related supplies 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 coinsurance for DME and related supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additionally for the dentures (D5110 and D5120).

You asked the Plan to pay additionally for the dentures. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says your supplemental dental benefit clearly states that the enrollee is responsible for any amount above the dental maximum allowance. The Plan has already issued the maximum dental allowance of $1000, therefore, no further payment can be made.

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 at this time as the file shows that the Plan has already issued the maximum dental allowance of $1000 for the 2020 benefit year. Therefore, we decided that the Plan does not have to pay additionally for the dentures (D5110 and D5120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.

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 laboratory services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure does not improve outcomes compared to standard treatment.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental and investigational because of the wide variation in efficacy in the peer reviewed literature. Therefore, the request is deemed not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.