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

We decided that the Plan does not have to pay for the laboratory services rendered on June 27, 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 the testing is 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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you need to be in rehab so you don't continue to lose muscle mass and strength so you can return home safely. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and were diagnosed with a conversion reaction. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services provided on February 19, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that the services were rendered in good faith. The Plan denied your request. The Plan says authorization was not obtained.

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 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 ophthalmology services provided on February 19, 2021 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.

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.

The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for atrial fibrillation with rapid ventricular response and upper gastrointestinal bleeding. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on September 23, 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 procedure code 99291 is not supported.

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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 

We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documented time spent providing critical care services to the enrollee. 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 critical care services rendered on September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nephrology services provided on January 11, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that you thought your pain was a kidney problem. The Plan denied your request. The Plan says the required authorization was not obtained.

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 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 nephrology services provided on January 11, 2021 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for eighteen (18) additional PT visits.

You asked the Plan to pay for eighteen (18) additional PT visits. You say that the additional PT is medically necessary. The Plan denied your request. The Plan says the additional PT visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 eighteen (18) additional PT visits.

Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. You have had extensive therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been already authorized additional therapy to ensure competence in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of eighteen (18) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pay for eighteen (18) additional PT visits.
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 the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.

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 patient appears to be unstable, requiring short-term additional acute care services to help stabilize blood pressure and to correct the gastric leak which can be safely be received at the current acute care facility. The patient does not require services at the LTACH that are not already available at the current facility. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you are unable to function. The Plan denied your request. The Plan says you can be treated at a lower level of care.

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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the records provided, you do not have documented skilled nursing or therapy needs. You require supervision for safety. Your care needs at this point are custodial and can be provided at a lower level of care. 

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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the prophylaxis - adult (D1110) and bitewings - four radiographic images (D0274) provided March 8, 2021.

You asked the Plan to provide additional payment for the dental cleaning and bitewing x-rays. You say that you believe that out-of-network services should be covered. The Plan denied your request. The Plan says the services were covered up to the allowed amount. Since services were obtained out-of-network you are responsible for the costs billed above the allowed amount.

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 the dental cleaning and bitewing x-rays up to in-network benefit maximums.

We looked at the file and Medicare rules. In this case the dental services were obtained out-of-network. The Plan has covered the services up to the in-network benefit maximum. Therefore, we decided that the Plan does not have to provide additional payment for the prophylaxis - adult (D1110) and bitewings - four radiographic images (D0274) provided March 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for acute inpatient hospital care provided on December 6 to December 9, 2020, and on December 17 to December 23, 2020.

You asked the Plan to waive the copayments for acute inpatient hospital care. You say that the enrollee should not receive any bills. The Plan denied your request. The Plan says the correct copayments were 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $240 copayment for each day of days 1-7 of an inpatient hospital stay. 

The enrollee has been asked to pay $2,160, or a $240 copayment for each day of a 3-day inpatient hospital stay on December 6 to December 9, 2020, and for each day of a 6-day inpatient hospital stay on December 17 to December 23, 2020. 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 copayments for acute inpatient hospital care provided on December 6 to December 9, 2020, and on December 17 to December 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the $45 copayments charged for INR services provided from
May 6, 2020, to February 8, 2021.

You asked the Plan to waive these copayments. You say that you should only be charged for the testing
supplies and not an office visit. The Plan denied your request. The Plan says these copayments were charged
based on the claim submitted by the provider and the Plan contract agreement. Maximus partially overturned
the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract
language.

The Plan is correct in this case. 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 $45 copayment for specialist services.

When you send a specimen or INR information back to your provider for processing, the interpretation and/or
assessment of that information is a service and is chargeable based on Medicare and Plan guidelines. 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 $45 copayments charged for INR services provided from May 6, 2020, to February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on March 2, 2021 by an OON provider.

You asked the Plan to pay for the first intraoral periapical x-ray. You say that when you contacted the provider you were advised that they were in-network. The Plan denied your request. The Plan says you are responsible for the cost difference between the Plan's allowed amount and the provider's submitted fee as a non-participating dentist.

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, you are responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on March 2, 2021 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an optimizer smart implantable pulse generator.

You asked the Plan to pre-approve an optimizer smart implantable pulse generator. You say that the clinical information provided supports the medical necessity of the requested procedure. The Plan denied your request. The Plan says medical studies have not proven that the requested device is helpful for treatment of the enrollee's health problem.

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 an optimizer smart implantable pulse generator. Our reviewer says that an optimizer smart implantable pulse generator is not considered medically reasonable and necessary in this case. Our physician reviewer found cardiac contractility modulation therapy with the Optimizer device is a relatively newer technology which is FDA approved, but has limited randomized data showing modest benefit with regard to quality of life and walk time scores in patients already on maximal medical therapy. A recent small randomized clinical trial (160 patients) who were also already on optimal guideline directed medical therapy for CHF, showed improvement in peak VO2, improved exercise tolerance on 6-minute walk, quality of life scores and re-hospitalization.

This patient has persistent NYHA Class III symptoms but is not on full guideline directed medical therapy. His systolic blood pressure is adequate, and his renal function is normal and there are no reports of side effects with trials of these guideline medications. He is currently on moderate dose carvedilol but not on Entresto (ARNI) or ACE inhibitors, diuretics or aldosterone antagonists. Current published data for the use of this device, along with current FDA indication, would require persistent severe symptoms despite full guideline directed medical therapy. Based on the clinical information provided he is not on full guideline CHF therapy per the FDA indications. He would therefore not meet CMS criteria for medical reasonableness and necessity of this device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an optimizer smart implantable pulse generator have not been met. Therefore, we decided that the Plan does not have to pre-approve an optimizer smart implantable pulse generator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited emergency exam (D0140) and the root canal (D3310) provided on March 12, 2021 by the out of network provider.

You asked the Plan to pay for the dental services. You say that the doctor had to do an immediate root canal to prevent infection in your tooth. You say that this service saved your tooth. You also say that you are on a fixed income. The Plan denied your request. The Plan says 1 limited emergency exam is covered per calendar year. The Plan says that the frequency limit has been exceeded. The Plan says there is a $200 allowance for additional dental services. The Plan also says that you are responsible for any billed amount that exceeds the $200 benefit limit when the services are performed out of network.

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 limited emergency exam is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited emergency exam that you received on February 4, 2021. Additionally, the record shows that the Plan paid $200 towards the root canal. The Evidence of Coverage clearly states that you are responsible for any billed amount that exceeds the $200 benefit limit when the services are performed out of network. Therefore, we decided that the Plan does not have to pay for the limited emergency exam (D0140) and the root canal (D3310) provided on March 12, 2021 by the out of network provider.