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

We decided that the Plan does not have to pay for SNF services provided from January 16, 2020, through January 31, 2020.
You asked the Plan to pay for the SNF services. You say that the SNF services were medically necessary. The Plan denied your request. The Plan says the SNF services are not reasonable and necessary based on CMS criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that at the time of admission, the enrollee required skilled rehabilitation services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of January 16, 2020 the enrollee did not require any skilled nursing or rehabilitation services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care as of January 16, 2020. The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved, however her function had plateaued by January 16, 2020 and she did not require any further inpatient skilled rehab services. The enrollee's function was at or near her prior level of function and she could be discharged to a lower level of care for further services. As of January 16, 2020 the enrollee required custodial services. The denial for further inpatient skilled care is upheld. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from January 16, 2020, through January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 pre-approve the monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria requires three shots of insulin per day to qualify for the requested monitor. You are only taking one shot of Lantus per day. Hence, the 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 the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an immediate upper denture (D5130) and a partial lower denture (D5214).
You asked the Plan to pre-approve the dentures. You say that these dentures are necessary. The Plan denied your request. The Plan says dentures are not covered by your dental benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 an immediate upper denture (D5130) and a partial lower denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Zoster Vaccine (Current Procedural Terminology (CPT) code 90750) provided on January 7, 2021.
You asked the Plan to pay for the vaccine. You say that you were not aware that you had to go to CVS for this vaccine. The Plan denied your request. The Plan says the Zoster vaccine is a Medicare Part D vaccine and is not eligible for coverage under Medicare Part B.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the vaccine.
Therefore, we decided that the Plan does not have to pay for Zoster Vaccine (Current Procedural Terminology (CPT) code 90750) provided on January 7, 2021.
Benefits for the vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share amount for the skilled nursing facility (SNF) care provided from January 26, 2021, to February 9, 2021.
You asked the Plan to waive the cost share amount for the SNF services. You say that you were sent to the facility to monitor the progress of your wound. You say that all the provider did was put a bandage on it. You also say that you were very upset with the time that you spend in the facility. The Plan denied your request. The Plan says you pay $20 per day for the first 20 days in SNF care. The Plan says that skilled services were provided for 14 days. The Plan also says that services provided for 14 days at the rate of $20 per day is a total of $280.
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 per day for days 1 through 20 of a benefit period for Skilled Nursing Facility (SNF) Care. You have been asked to pay $20 per day for days 1 through 20 of a benefit period for the SNF services. the SNF services falls within the Skilled Nursing Facility (SNF) 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 cost share amount for the skilled nursing facility (SNF) care provided from January 26, 2021, to February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on March 3, 2021.
You asked the Plan to pay for the dental service. You say that this service should be covered. You also say that you signed up for dental coverage, effective February 21, 2021. The Plan denied your request. The Plan says complete series x-ray is not listed as a covered service.
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 complete series x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the needle localization by x-ray provided on December 3, 2020, December 10, 2020, and December 17, 2020.
You asked the Plan to waive the copayment for fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure) (77002). You say that you were not told you were responsible for paying for x-rays. The Plan denied your request. The Plan says you were charged this coinsurance 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 $35 copayment for Outpatient Diagnostic Tests. You have been asked to pay a $35 copayment for fluoroscopic guidance (77002). Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure) (77002) falls within the Outpatient Diagnostic Tests 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 needle localization by x-ray provided on December 3, 2020, December 10, 2020, and December 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an immediate partial upper denture (D5223).
You asked the Plan to pre-approve the denture. You say that this denture is medically necessary. The Plan denied your request. The Plan says this type of denture is not covered by the Plan's dental benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 an immediate partial upper denture (D5223).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0429) received November 14, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were transferred from one hospital to another hospital because the first hospital could not treat your condition. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $300 copayment for Ambulance Services. You have been asked to pay a $300 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transportation (A0429) received November 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479) provided September 2, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the genetic testing at issue is non-covered.
The Plan must follow Medicare rules. Medicare rules say that this type of genetic testing is only covered when the record shows the clinician has made an initial personalized decision for the patient based on the patient's diagnosis, the patient's other medical conditions, other medications the patient is taking, professional judgement, clinical science and basic science pertinent to the drug (e.g. mechanism of action, side effects), the patient's past medical history and when pertinent family history and the patient's preferences and values We looked at the file and Medicare rules. Insufficient clinical documentation was provided to determine if Medicare coverage criteria was met in this case. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479) provided September 2, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you need SNF services. The Plan denied your request. The Plan says your needs can be met safely from home health services or in an assisted living facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care (ex. home, AL, LTC). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammography provided on February 2, 2021.
You asked the Plan to waive the copayment for the diagnostic mammography (77066). You say that this was your first mammogram this year so you should have zero copayment. The Plan denied your request. The Plan says this was a diagnostic mammogram, so you were charged the 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 $100 copayment for Outpatient Diagnostic Tests.
You have been asked to pay a $100 copayment for the diagnostic mammography (77066). The claim was submitted as diagnostic mammography not screening mammography. The diagnostic mammography (77066) falls within the Outpatient Diagnostic Tests 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 diagnostic mammography provided on February 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided December 7, 2019 to December 8, 2019.
You asked the Plan to pay for the inpatient services. You say that DRG 196 was correctly billed. The Plan denied your request. The Plan says the documentation does not support DRG 196. DRG 197 is more appropriate.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 196. 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 inpatient services. Our reviewer says that DRG 196 is not supported in the records. Our physician reviewer found the clinical presentation suggests that the elevated troponin was related to non-infarction related issues (kidney failure, atrial fibrillation, pulmonary) rather than myocardial infarction for which there was no other supportive subjective or objective evidence provided. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided December 7, 2019 to December 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211).

You asked the Plan to pre-approve a partial upper denture. You say that your partial denture broke, and you need a new one. The Plan denied your request. The Plan says this service has been covered in the past 5 years and therefore is not currently eligible for coverage.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a partial upper denture once every five plan years.

We looked at the file and Medicare rules. The Plan provided documentation showing that a partial upper denture was previously covered on March 14, 2019. Based on this information, we determined that the Plan's frequency limit for coverage of a partial upper denture has already been met. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5211).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a human floor lift device (Current Procedural Terminology (CPT) code E1399).

You asked the Plan to pre-approve the floor lift. You say that you need this item in your home. The Plan denied your request. The Plan says a floor lift device (E1399) is not considered a medically necessary item and also not a covered item per the Centers for Medicare and Medicaid (CMS) guidelines

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 human floor lift device (Current Procedural Terminology (CPT) code E1399).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 25, 2020, by an out-of-network provider.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 laboratory services provided on June 25, 2020, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) and unspecified preventative procedure, by report (D1999) provided February 25, 2021.
You asked the Plan to pay for the intraoral x-rays and unspecified preventative procedure. You say that you did not know at the time of the x-rays that they would not be covered. The Plan denied your request. The Plan says these services are not covered under your benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
intraoral - complete series of radiographic images (D0210) and unspecified preventative procedure, by report (D1999) provided February 25, 2021.
Your complaint about feeling you were given misinformation about providers and services covered by the Plan when signing up for insurance is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 29, 2020.
You asked the Plan to pay for lab services provided to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial stating this lab service was medically necessary. The Plan requested a reopen and stated that the issue was not medical necessity but that the claim cannot be paid as billed. The Plan says that this was an administrative denial for coding errors. The Plan states Medicare denies assays that are done for two or more genes in a patient in parallel. The two or more genes would be viewed as part of the same panel. Since a panel constitutes a single procedural service, only one HCPCS code should be submitted.
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. In this case the claim submitted cannot be paid as billed due to an error with services being billed separately that are considered the same or a singular service. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on July 29, 2020.