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

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnight. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnight or more.

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 acute inpatient hospital care.

Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnight.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
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. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer.
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 physician reviewer found that you presented to the hospital with minimal response requiring intubation for acute respiratory failure, severe sepsis, and stroke. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. Therefore, the requested LTACH services are not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 services provided by an out-of-network provider on February 27, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the services provided by an out-of-network provider on February 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for bone density scan of axial bones like hip, pelvis and spine (77080) provided September 24, 2020.
You asked the Plan to pay for the diagnostic service. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says with the information provided it cannot be determined how the enrollee came to the servicing provider, or whether the services are medically necessary.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 77080 is dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites. We find that CPT code 77080 is not supported in the medical record. Specifically, there is insufficient documentation to corroborate the services and confirm Medicare coverage has been met. With the information provided, it cannot be determined how the enrollee came to the servicing provider, or whether the services are medically necessary. The plan had made multiple attempts to obtain the additional information from the provider without success. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for bone density scan of axial bones like hip, pelvis and spine (77080) provided September 24, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health care services to be provided by
a Licensed Professional Counselor (LPC).

You asked the Plan to pre-approve LPC services. You say that you have established a trusting relationship with
this provider. The Plan denied your request. The Plan says the denial of authorization for these services is
correct, because this provider is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible
to participate in Medicare and is therefore not covered.

We looked at the file and Medicare rules. This provider is a Licensed Professional Counselor, which is not
covered by Medicare. Based on this information, we decided that Medicare rules for coverage of LPC services
have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient mental health
care services to be provided by a Licensed Professional Counselor (LPC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on February 23,
2021.
You asked the Plan to pay for periodontal maintenance. You say that you had cleanings with this code covered
in previous years. You feel this service should be covered as a cleaning. The Plan denied your request. The
Plan says this service is not covered by your 2021 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. The Plan can cover two
cleanings per year. Codes listed as covered in the dental benefits chart include: D1110 - Adult prophylaxis. No
other codes are listed as covered preventative cleanings. Per the Plan's contract, only codes listed in this chart
are eligible for coverage.
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
periodontal maintenance (D4910) provided on February 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total knee arthroplasty (27447).
You asked the Plan to pre-approve a total knee arthroplasty (27447). You say that the requested total knee arthroplasty (27447) is medically necessary. The Plan denied your request. The Plan says the requested total knee arthroplasty (27447) 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 a total knee arthroplasty (27447). Our reviewer says that the requested total knee arthroplasty (27447) is not medically necessary. Our physician reviewer found the enrollee has osteoarthritis of the right knee. Imaging demonstrates mild bi-compartmental disease that the provider indicates is insufficient to account for the enrollee's symptoms. The enrollee has not had a course of physical therapy. The provided medical records do not support the medical necessity and reasonableness of the requested services. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a total knee arthroplasty (27447) have not been met. Therefore, we decided that the Plan does not have to pre-approve a total knee arthroplasty (27447).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from January 11, 2021, to January 21, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you feel that you should not owe this much for a hospital stay. 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 $325 copayment for days 1-5 for inpatient hospital care. 

You had an inpatient hospital stay from January 11, 2021, to January 21, 2021. Therefore, you are responsible to pay a $325 copayment for days 1-5 (January 11, 2021, to January 15, 2021). The total amount you owe is: $325 (copayment) x 5 (inpatient days) = $1,625. 

You have been asked to pay the total copayment amount of $1,625 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided from January 11, 2021, to January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
December 22, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at issue in this appeal. The Plan did not pre-approve the
services at issue. 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 the services provided by an out-of-network provider on
December 22, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules.Explanation of decisionWe decided that the Planhasto pay forthe periodontal maintenance services provided on January 14, 2021.You asked the Planto pay forthe periodontal maintenance. You say that you feel that this should be covered as you require these services on a semi-annual basis.The Plandenied your request. The Plansaysthatthis is not a covered service.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan's denial rationale is based on the service at issue not being list as covered in your Evidence of Coverage (EOC) or Summary of Benefits. However, the Plan did not forward the full text of either of these documents to Maximus with the case file. A request was made on June 23, 2020 requesting that the Plan submit these documents. These were not received within the appeal time frame. Without access to these documents, we cannot determine whether you were reasonably aware that the services at issue would be noncovered. As such, the Plan's denial of payment is not substantiated.Therefore, we decided that the Planhas to pay forthe periodontal maintenance services provided on January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor treatment field therapy.

You asked the Plan to pre-approve the requested services. You say that this is the most appropriate option for the enrollee at the present time. The Plan denied your request. The Plan says the request 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 looked at the file, and Medicare rules. Tumor treatment field therapy will be denied as not reasonable and necessary for the treatment of recurrent GBM. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve tumor treatment field therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on January 6, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you cannot afford the charges and want to know if the charges are legitimate. 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 Medicare Part B prescription drugs. You received Medicare Part B drugs on January 6, 2021. The total allowed amount is $10,490.96 and 20% of that is $2,098.19. You have been asked to pay the total coinsurance amount of $2,098.19 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 Medicare Part B drugs provided on January 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation (D9310).

You asked the Plan to pre-approve a consultation. You say that the service is medically necessary. The Plan
denied your request. The Plan says the service is not covered.

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. Specifically, the provider does not participate with the Plan's dental
network. Therefore, we decided that the Plan does not have to pre-approve a consultation (D9310).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from March 30, 2020, to April 9, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with how the claim processed. 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 $380 copayment for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from March 30, 2020, to April 9, 2020. Therefore, you are responsible to pay a $380 copayment for days 1-5 (March 30, 2020, to April 4, 2020). $380 (copayment) x 5 (inpatient days) = $1,900. You have been asked to pay the total copayment amount of $1,900 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided from March 30, 2020, to April 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 17, 2020.

You asked the Plan to pay for the dental service. You say that you do not agree with the billing on this claim. You say that you have always gone to the same dental office. You also say that you have never been to the dental office listed on your bill. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that you did not call to verify your benefits prior to the date of service. The Plan also says that the dental office listed on your bill is doing business as Metro Dentalcare.

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 limited oral evaluation (D0140) provided on November 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from November 26, 2020, to November 30, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges because you feel that you were discharged too soon from a previous stay. 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 $295 copayment for days 1-7 for inpatient hospital care. You had an inpatient hospital stay from November 26, 2020, to November 30, 2020. Therefore, you are responsible to pay a $295 copayment for days 1-4 (November 26, 2020, to November 29, 2020). $295
(copayment) x 4 (inpatient days) = $1,180. You have been asked to pay the total copayment amount of $1,180 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay from November 26, 2020, to November 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozempic 2mg/1.5ml (C9399).
You asked the Plan to pre-approve Ozempic. You say that Ozempic is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic 2mg/1.5ml (C9399).
Benefits for Ozempic 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (CPT 99601) provided to the enrollee
from May 12, 2020 to July 8, 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 this code is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 99601 is not supported in the medical record. Specifically, this code has a status
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for
Medicare purposes. 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 home health services (CPT
99601) provided to the enrollee from May 12, 2020 to July 8, 2020.