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

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received 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. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for lumbar spinal surgery and has been discharged home with home health services. There is ongoing weakness and difficulty ambulating. Medical problems 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. 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 the 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0367) and comprehensive oral evaluation (D0150) provided on October 23, 2020.
You asked the Plan to pay for the cone beam CT capture and interpretation and comprehensive oral evaluation. You say that you would like these services to be covered. The Plan denied your request. The Plan says the cone beam CT capture and interpretation is not covered under your plan. The Plan also says that the comprehensive oral evaluation has exceeded the maximum count allowed per period.
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 cone beam CT capture and interpretation is not among those covered under this benefit. The contract says that comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on October 10, 2019 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0367) and comprehensive oral evaluation (D0150) provided on October 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 6, 2020.
You asked the Plan to waive the copayment for urgent care visit. You say that your urgent care copayment should be $50. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $55 copayment for urgent care visit. You have been asked to pay $55 copayment for urgent care visit. Urgent care visit falls within the Urgently Needed 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 an urgent care visit provided on October 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and bitewing x-ray (D0270) provided on August 4, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation and bitewing x-ray. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services exceeded the frequency limitation in your benefit plan.
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, problem focused limited oral evaluation (D0140) and bitewing x-ray (either code D0270, D0272, D0273, D0274, or D0277) are limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on July 9, 2020, and bitewing x-rays (D0274) on June 23, 2020, and your problem focused limited oral evaluation (D0140) and bitewing x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and bitewing x-ray (D0270) provided on August 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous sacral augmentation (sacroplasty) for the enrollee.

You asked the Plan to pre-approve percutaneous sacral augmentation (sacroplasty) for the enrollee. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the Medicare LCD coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria in the LCD.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for sacroplasty. The Maximus Physician Reviewer determined the treatment to be reasonable and necessary. The Plan requested a reopen and stated that the criteria outlined in the relevant LCD L35130 were not met in this case. Our Medical Director says that the medical records show the enrollee the enrollee is an 88-year-old woman with bilateral sacral fractures. Our Medical Director has concluded the Plan is correct in this case. Per LCD L35130, Percutaneous Vertebral Augmentation for Vertebral Compression Fracture services are not indicated for the sacrum or coccyx. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous sacral augmentation (sacroplasty) have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous sacral augmentation (sacroplasty) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for current procedural terminology (CPT) code 29823 provided on October 14, 2020.
You asked the Plan to pay for CPT code 29823. You say that the medical records support the billing of CPT code 29823. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 29823.
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 29823 is Arthroscopy, shoulder, surgical; debridement, extensive. 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 CPT code 29823. Our reviewer says that the medical records do not support the billing of CPT code 29823. Our physician reviewer found the operative note for the shoulder scope procedure does not support the CPT 29823 code. Specifically, debridement of 3 additional structures where no other work was performed is not documented. The debridement and symovectomy described is bundled and included in the arthroscopy code. The 29823 should not be approved. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 29823 have not been met. Therefore, we decided that the Plan does not have to pay for current procedural terminology (CPT) code 29823 provided on October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additionally for the dental services (D9243) provided on January
7, 2020.
You asked the Plan to pay additionally for the dental services. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says you have reached your dental
services allowance of $150 for the 2020 benefit year. The Plan says that the $150 was paid to your provider.
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.
We looked at the file, the Plan's contract and Medicare rules. The Plan contract clearly says there is a $150
dental-services allowance every year for Non-Medicare covered preventive dental services and Non-Medicare
covered comprehensive dental services combined. You are responsible for any amount above the dental
coverage limit. The file shows that the Plan paid the dental provider the $150 allowed amount for dental code
D9239. The is means you are responsible for any amount over this limit. Therefore, we decided that the Plan
does not have to pay additionally for the dental services (D9243) provided on January 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 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 a stroke with incomplete left hemiplegia. 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 acute IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health aide for up to 8 hours per day.
You asked the Plan to pre-approve a home health aide. You say that you need a home health aide for up 8 hours per day. You also say that this is medically necessary. The Plan denied your request. The Plan says the services must be on a part time basis. The Plan says that your doctor ordered a home health aide to assist you on an hourly basis. The Plan also says that hourly care is more than the reasonable frequency. and is considered custodial.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 pre-approve a home health aide. Our reviewer says that the home health aid is not medically necessary. Our physician reviewer found Based on the documentation provided, you do not have documented skilled nursing needs. The reviewer found that you do not have documented skilled therapy needs. Therefore, the reviewer found that the home health aid is 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 a home health aide have not been met. Therefore, we decided that the Plan does not have to pre-approve a home health aide for up to 8 hours per day.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery.
You asked the Plan to pre-approve spinal surgery. You say that the services are necessary. The Plan denied
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not
been met.
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 spinal surgery. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the spinous process spacer device is experimental. More research is needed to show safety and
efficacy of the device. Open laminectomy remains the gold standard procedure for spinal stenosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of spinal surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve spinal surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Providence DTRAX instrumentation (CPT code 22840 and 22842), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says medical studies haven't proven that the device(s) is helpful for treatment of your 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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the DTRAX cage system remains experimental for use in the posterior cervical spine. More research is needed to show safety and efficacy. The DTRAX posteriorly has not been clinically proven. Anterior cervical cages have been proven, but not posterior. The DTRAX should be denied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve Providence DTRAX instrumentation (CPT code 22840 and 22842), for the enrollee.
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 August 6, 2020, to August 13, 2020.
You asked the Plan to waive the copayment for inpatient stay. You say that you were told there would be no copayment for this admission because it was a complication from a previous admission. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $295 copayment per day for days 1 to 5 for in-network inpatient stay. This inpatient stay lasted 7 days, resulting in a copayment obligation of $1,475. You have been asked to pay $295 copayment per day for days 1 to 5 for inpatient stay. Inpatient 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 August 6, 2020, to August 13, 2020.
Your complaint regarding receiving inaccurate information about the cost-sharing for this service is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator with a non-invasive interface.
You asked the Plan to pre-approve a home ventilator with a non-invasive interface. You say that the enrollee
uses AVAPS at home. You say that the enrollee was started on this during a hospitalization. You say that this
machine has drastically limited the frequency and duration of hospitalizations. You say that the device has been
very cost effective and lessened the enrollee's morbidity. The Plan denied your request. The Plan says the
criteria for coverage have not been met.
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 home ventilator with a non-invasive
interface. Our reviewer says that the requested home ventilator is not considered medically reasonable and
necessary in this case. Our physician reviewer found the enrollee has a diagnosis of COPD, but there are no
confirmatory pulmonary function data. A home ventilator in AVAPS-AE mode was prescribed after a
hospitalization for pneumonia in 2019. However arterial blood gas data showed there was no CO2 retention.
The enrollee therefore does not meet criteria for positive pressure respirator support. In addition, the ventilator
is being used as BiPAP, which is not covered by Medicare.
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 home ventilator with a non-invasive interface have not been met. Therefore,
we decided that the Plan does not have to pre-approve a home ventilator with a non-invasive interface.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and each additional intraoral periapical x-ray (D0230) provided on July 28, 2020.
You asked the Plan to pay for the intraoral periapical x-rays. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.
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 first intraoral periapical x-ray (D0220) and each additional intraoral periapical x-ray (D0230) provided on July 28, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the genetic testing provided on September 11, 2020.
You asked the Plan to pay for the genetic testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 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 did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that these tests would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for these services is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for the genetic testing provided on September 11, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.