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

We decided that the Plan does not have to pay for subsequent hospital care (99233) provided on September 1, 2020, through September 3, 2020.
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the diagnosis code submitted was not valid on the billed date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 99233 is not supported in the record. Specifically, per the CD-10-CM Official Guidelines for Coding and Reporting FY 2020, diagnosis code N18.30 was not yet valid. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99233) provided on September 1, 2020, through September 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs to wheelchair seat or back cushion (K0669).
You asked the Plan to pre-approve repairs to wheelchair seat or back cushion. You say that you have worked to narrow down the request for repairs to only what is necessary. The Plan denied your request. The Plan says the repairs are approved except for the wheelchair seat or back cushion which does not meet specific code criteria.
The Plan must follow Medicare rules. Medicare rules say that if the prefabricated seat cushion, prefabricated back cushion, or a brand name custom fabricated seat or back cushion has not received a written coding verification review (CVR) from the PDAC or if the PDAC has reviewed and determined that the product does not meet the criteria for the code, then it must be billed with code K0669 which will then be denied as not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of repairs to wheelchair seat or back cushion have not been met. Therefore, we decided that the Plan does not have to pre-approve repairs to wheelchair seat or back cushion (K0669).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastroenterology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are in-network providers available who can supply the requested service.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve gastroenterology services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided by an out-of-network provider.

You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the therapist was given as a possible provider for the earliest appointment available. 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 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 psychiatric diagnostic evaluation provided by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a participating provider.

You asked the Plan to waive the copayment for ambulance services. You say that you were taken to the hospital which was a four-minute drive. You say that this is a rip off. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $275 copayment for ambulance services/ambulance transport.

You have been asked to pay a $275 copayment for ambulance services. The correct copayment has been applied to the services that were provided. Ambulance services fall within the ambulance services/ambulance transport 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 ambulance services provided by a participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan.

You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the charges because they are related to COVID-19 symptoms. 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 $100 copayment for advanced imaging services provided at outpatient hospital facilities.

You have been asked to pay a $100 copayment for a CT scan. A CT scan 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 a CT scan.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat facet joint injections.
You asked the Plan to pre-approve facet joint injections. You say that you are in pain and need this procedure in order to relieve your pain. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the documentation does not show that the previous procedure provided 50% or more improvement of pain and improved your activities of daily living for at least 6 months.
The Plan follows Medicare rules. Medicare rules say that repeat denervation procedure for the same joint will only be considered medically necessary if the patient experienced 50% or more improvement of pain and improvement in ADLs for at least 6 months. 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 facet joint injections. Our reviewer says that you do not meet the Medicare criteria for the requested repeat facet joint injections. Our physician reviewer found you have had physical therapy, massage therapy, cold packs, and transcutaneous electrical nerve stimulation (TENS). You have tried medications. You had left radiofrequency ablations which provided only 1 months of pain relief. Therefore, the prior treatment does not meet the criteria for coverage of repeat facet joint injections and therefore this 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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat facet joint injections.
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 these services are medically necessary. The Plan denied your request. The Plan says that your care could be provided in an alternate setting such as a skilled nursing facility.
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. You are receiving appropriate care at the present acute care hospital. The review indicates that you do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. Our physician reviewer found that your 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider.

You asked the Plan to pay for the home visit. You say that there is a medical necessity pre-established to provide services to patients needing care. You say that the claim should be processed for reimbursement. 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 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 home visit provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy (36482, 36483).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that ERFA of varicose veins may be considered medically necessary for enrollees without the presence of significant peripheral arterial disease. 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 this service. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found that the documentation does not meet coverage criteria and does not support the medical necessity of the procedure. There is clear documentation in the medical record of peripheral artery disease. After an initial denial was made based at least in part on this, the patient returned to the office for the purpose of ruling out peripheral artery disease. At that evaluation there is conspicuous absence of a pulse examination or any other objective determination of arterial perfusion to the lower extremities. There is, however, documentation that the patient has no edema. Satisfactory arterial perfusion to the lower extremities has not been demonstrated in the medical record. The only objective documentation of the patient's lower extremity arterial perfusion is that there is peripheral artery disease.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation therapy (36482, 36483).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for pathology services provided by a
participating provider on November 25, 2020.
You asked the Plan to waive the coinsurance for pathology services. You say that there was no mention that
there would be any lab costs. You say that you should not have to pay for any costs related to your
colonoscopy. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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 20%
coinsurance for outpatient diagnostic tests/laboratory tests.
You have been asked to pay a 20% coinsurance of the allowed amount for pathology services. Pathology
services fall within the outpatient diagnostic tests/laboratory tests benefit category. The total allowed amount is
$38.49. The total amount you are being asked to pay is $7.70 ($38.49 x 20% = $7.70). 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 pathology services provided by a participating provider on
November 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation system (E2300).
You asked the Plan to pre-approve the power seat elevation system. You say that this item is necessary for the enrollee's condition. The Plan denied your request. The Plan says a seat lift does not serve a medical purpose and cannot be covered.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan does not have to pay for dental services provided on August 12, 2020.
You asked the Plan to pay for services dental services which you believe should be covered by the Plan. The Plan denied your request. The Plan says this provider has opted out of Medicare and dental services provided by this type of provider are not covered by the Plan. Maximus overturned the Plans denial stating the Plan did not provide documentation of the providers "Opt-out" status. The Plan requested a reopen and provided additional information which confirmed this providers Medicare status.
The Plan is correct in this case. 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. The Plan has provided documentation which shows the provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental services provided on August 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for emergency care, inpatient hospital care and observation services.

You asked the Plan to waive the copayments for emergency care, inpatient hospital care and observation services. You say that you disagree with the charges because they are related to a reaction to a medication. 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 $90 copayment for emergency care. Your contract with the Plan also clearly says that you must pay a $250 copayment for days 1-6 for inpatient hospital care. Your contract with the Plan also clearly says that you must pay a $375 copayment for outpatient hospital services.

You have been asked to pay the total copayment amount of $1,895 for emergency care, inpatient hospital care and observation services. Emergency care falls within the emergency care benefit category. Inpatient hospital care falls within the inpatient hospital care benefit category. 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 copayments for emergency care, inpatient hospital care and observation services.
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 you need LTACH services. The Plan denied your request. The Plan says you can safely receive necessary care in another setting.
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 documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The review indicates that the enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria for an IRF based on Medicare guidelines.
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical treatment of a fracture of the humerus after a fall. The enrollee's medical problems are stable. 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 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 this 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided by an out of network (OON) provider.

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services were not urgent or emergent and there are network providers available.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 drug testing services (G0483) provided by an out of network (OON) provider.