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

We decided that the Plan does not have to pre-approve abdominoplasty and panniculectomy.
You asked the Plan to pre-approve abdominoplasty and panniculectomy. You say that this surgery 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. At issue is whether complex abdominoplasty and panniculectomy is a covered service in this case. The Maximus Physician Reviewer determined that the procedure is medically reasonable. The Plan requested a reopen and stated that the medical records do not indicate a 3-month trial of medical therapy for persistent cellulitis, abscesses or ulcerations. A second review of the medical records shows the documentation indicates that there are no rashes, no back pain and no interference with activities of daily living. In fact, the provider note indicates that that they consider the procedure cosmetic. The medical records do not support the medical necessity and reasonableness of the requested procedure as defined by Medicare rules. Medicare coverage criteria are not 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 abdominoplasty and panniculectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve abdominoplasty and panniculectomy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that records do not show LTACH treatment is required at this level of care due to treatment complexity.

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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 

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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a queen air mattress.
You asked the Plan to pre-approve the mattress. You say that this will help provide a better quality of life. The Plan denied your request. The Plan says this mattress is not presumptively medical.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a queen air mattress.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services that you provided on July 13, 2020, and September 3, 2020.
You asked the Plan to pay for the dental services provided on July 13, 2020, and September 3, 2020. You say that none of the materials or enrollment packet indicated that the dentist had to accept Medicare. You say that you assumed you would be reimbursed up to $400. You also say that you believe that these services should be covered due to limited information provided by the plan. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made for dental services performed by a provider who has opted out of Medicare.
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 and the services could be covered, the requested items or services are not among those covered under this benefit when performed by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the dental services that you provided on July 13, 2020, and September 3, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from
February 12, 2021, to February 13, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that you were admitted to
the hospital and the emergency copayment does not apply. The Plan denied your request. The Plan says you
have been asked to pay 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 a $120
copayment for emergency services provided at an in-network emergency room.
You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency care" benefit category. The record shows you were considered an outpatient. 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 emergency room visit from February 12, 2021, to
February 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on October 1, 2020.

You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular disease screening tests are only covered for certain indications.

The laboratory services at issue in this appeal were requested solely for screening purposes. While Medicare covers cardiovascular disease screening tests for certain indications, the documentation does not support that the enrollee met criteria for the services rendered. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on December 14, 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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 lumbar-sacral orthosis rendered on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup (D2950) for tooth #22.
You asked the Plan to pre-approve the core buildup. You say that this service is necessary. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental 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 core buildup (D2950) for tooth #22.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pharmacogenomic testing provided on May 18, 2020.
You asked the Plan to pay for pharmacogenomic testing. You say that this testing is mandated by the state and was medically necessary. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because there is no evidence that this testing was ordered due to any signs/symptoms of a drug reaction and this testing is not covered for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, pharmacogenomic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. If this testing was ordered as a result of a routine examination required by a state government agency, the purpose of the examination would not be covered by Medicare. Therefore, we decided that the Plan does not have to pay for pharmacogenomic testing provided on May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99285) provided September 21, 2020.

You asked the Plan to pay for the emergency visit. You say that the claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99285) provided September 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 1, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on November 6, 2020.
You asked the Plan to waive the copayment for an MRI. You say that you were not made aware that you would owe a copayment. 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 $225 copayment for diagnostic radiology. You have been asked to pay a $225 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 provided on November 6, 2020.
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 is no evidence that the enrollee requires services that are not currently
available. As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is
no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for
any ongoing long-term care (LTC) needs.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 6, 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 the denied services are part of an expanded pharmacogenomic panel.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific clinical rationale for the requested services. The code represents part of an expanded pharmacogenomic panel. The review indicates that the enrollee did not meet the criteria for this request.

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 pay for laboratory services provided to the enrollee on November 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the custodial care services provided from November 15, 2020, to December 14, 2020.
You asked the Plan to pay for the custodial care. You say that the services provided are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee no longer required daily skilled nursing services or skill therapy services on the dates of service in this case. The Plan says that there is no added benefit for custodial care that goes beyond the Medicare benefit.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custodial care have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the custodial care services provided from November 15, 2020, to December 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for gene analysis provided on May 28, 2020 by an out of network (OON) provider.

You asked the Plan to pay for gene analysis. You say that your lab performed all the tests that were ordered by the referring physician. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 gene analysis provided on May 28, 2020 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage and the non-emergency transport provided on July 18, 2020.

You asked the Plan to pay for the transportation services. You say that the enrollee's plan paid for the services initially. You say that payment was recouped. You say that you received an additional payment recovery letter, and that the payment was recouped a second time. You also say that you should be reimbursed for the additional recouped payment. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Additionally, the Plan confirmed that recoupment was only requested once and received once. Therefore, we decided that the Plan does not have to pay for the ground mileage and the non-emergency transport provided on July 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from September 30, 2020, through October 9, 2020.

You asked the Plan to waive the copayment for the inpatient stay. You say that the $6,700 limit was reached so the charge should be less. The Plan denied your request. The Plan says the copayment applied 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $345 copayment each day for days 1 to 5 for Medicare-covered hospital care. $0 copayment for additional Medicare-covered days. 

The enrollee has been asked to pay a $1,725 copayment for the inpatient stay. ($345/day x 5 days = $1,725). The inpatient stay falls within the "Inpatient Hospital Care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay provided from September 30, 2020, through October 9, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage and the non-emergency transport provided on August 21, 2020.
You asked the Plan to pay for the transportation services. You say that the enrollee's hospice election was not effective until after the ambulance transport from the hospital to the nursing home. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Hospice coverage begin on the date of service, regardless of the time. Therefore, we decided that the Plan does not have to pay for the ground mileage and the non-emergency transport provided on August 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the capsule endoscopy (91110) provided September 23, 2020.

You asked the Plan to pay for the capsule endoscopy. You say that this service was medically necessary. The Plan denied your request. The Plan says the capsule endoscopy was not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the capsule endoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 71-year-old male with anemia. Of note, the study report documents no pathology in this case. Based on the records provided, the enrollee met none of the standard-of-care and community-recognized indications for the capsule endoscopy. 

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 capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pay for the capsule endoscopy (91110) provided September 23, 2020.