Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mounting hardware for joystick, and wheel lock assembly.

You asked the Plan to pre-approve wheelchair accessory, manual swing away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (E1028) and manual wheelchair accessory, wheel lock assembly, complete, replacement only, each (E2206). You say that you need a manual wheelchair and accessories. The Plan denied your request. The Plan says the wheel lock assembly E2206 is included in the allowance for the manual wheelchair base and code E1028 cannot be used for tray hardware.

The Plan must follow Medicare rules. Medicare rules say that options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wheelchair accessory, manual swing away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (E1028) and manual wheelchair accessory, wheel lock assembly, complete, replacement only, each (E2206) have not been met. Therefore, we decided that the Plan does not have to pre-approve the mounting hardware for joystick or wheel lock assembly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received from March 15, 2021, to March 29, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim processed 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 $20 copayment for Medicare-covered chiropractic services. The rules also say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

Review of the file shows that you were provided manual manipulation services (98941) from March 15, 2021,

to March 29, 2021. You have been asked to pay a $20 copayment for each of these services. 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.

Additionally, the records show that the other services at issue (99213, 98943) are not manual manipulation of the spine.

Therefore, we decided that the Plan does not have to pay for the chiropractic services you received from March 15, 2021, to March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the six surgical placements of implant bodies: endosteal implants (D6010 x6), six bone grafts at time of implant placement (D6104 x6), first 15 minutes of deep sedation/general anesthesia (D9222), and each subsequent 15 minute increment of deep sedation/general anesthesia provided on April 9, 2021.

You asked the Plan to pay for the endosteal implants, bone grafts, and deep sedation/general anesthesia services. You say that your provider advised you have these services done, and you believe they should be covered. The Plan denied your request. The Plan says these services are not covered under your 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 six surgical placements of implant bodies: endosteal implants (D6010 x6), six bone grafts at time of implant placement (D6104 x6), first 15 minutes of deep sedation/general anesthesia (D9222), and each subsequent 15 minute increment of deep sedation/general anesthesia provided on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 2, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for the office visit provided on November 2, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) services.

You asked the Plan to pre-approve the CT scan. You say that the requested CT scan is medically necessary. The Plan denied your request. The Plan says the enrollee has had stable findings and the requested scan is not supported by evidence-based guidelines, nor is there evidence that it is medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

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 CT scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is a former smoker (30 pack year) with dyspnea and pulmonary nodules. August 2020 showed 9 mm right upper lobe ground glass focus and 7 mm nodular density right minor fissure, stable from prior images from 2018 and 2019. Repeat CT of the chest was requested for surveillance. Fleischner guidelines suggest these type of ground glass opacities should be followed up 6-12 months after first diagnosis, then every two years until year 5. The last image was less than one year ago when a two-year time span is warranted for this clinical scenario. Therefore, this request for CT is premature for surveillance and there were no other acute clinical issues to justify this request. The CT is not currently considered 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond July 13, 2021.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the continued services are not medically necessary.

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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to the SNF on June 21, 2021 after spine surgery. You have no skilled nursing needs. Your current functional level does not require daily skilled therapy services. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the polycarbonate lens and tinting provided on March 22, 2021.

You asked the Plan to pay for the services provided. You say that you should not be responsible for the bill. The Plan denied your request. The Plan says the additional lens options are not covered.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. Although the Plan offers a vision benefit that exceeds Medicare coverage, the services at issue are not included in this benefit. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the polycarbonate lens and tinting provided on March 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on February 10, 2021.

You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

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 90837 is psychotherapy, 60 minutes with patient. 

We find that CPT code 90837 is not supported in the medical record. Specifically, this code was billed with diagnosis codes F06.4 (Anxiety disorder due to known physiological condition), M72.6 (Necrotizing fasciitis), E11.628 (Type 2 diabetes mellitus with other skin complications) and L08.9 (Local infection of the skin and subcutaneous tissue, unspecified). F06.4 was billed as the primary diagnosis.

There is an instruction note following code 'F06' which states "Code first the underlying physiological condition" which means that the physiological condition should be sequenced first and the codes from category F06 should be sequenced second. Therefore, code F06.4 is considered as a secondary diagnosis and cannot be used as a primary diagnosis. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided on February 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a CPAP is covered when specific criteria are met.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have obstructive sleep apnea. The records do not show that you have used the CPAP device for greater than or equal to four hours per night for 70 percent of the nights during a consecutive 30 day period. The criteria for coverage are not met and the CPAP is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the endodontic therapy (D3320).

You asked the Plan to pre-approve the endodontic therapy. You say that you do not have the finances to pay for this service. You also say that the tooth is causing pain. The Plan denied your request. The Plan says this 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. Therefore, we decided that the Plan does not have to pre-approve the endodontic therapy (D3320).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the Covid-19 testing provided from January 11, 2021, to February 1, 2021.

You asked the Plan to pay for the laboratory testing. You say that the services should be covered as mandated by the Cares Act. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.

The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. 

Therefore, we decided that the Plan does not have to pay for the Covid-19 testing provided from January 11, 2021, to February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) and an unspecified preventive procedure (D1999) provided on March 5, 2021.

You asked the Plan to pay for an adjunctive pre-diagnostic test and an unspecified preventive procedure. You say that you do not agree with the amount you have to pay. The Plan denied your request. The Plan says the services at issue are not covered 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 an adjunctive pre-diagnostic test (D0431) and an unspecified preventive procedure (D1999) provided on March 5, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to waive the copayment for skilled nursing facility (SNF) care provided on
February 8, 2021.

You asked the Plan to waive the copayment for SNF care. You say that you would like reconsideration because
you were ready to leave the SNF on February 7th but there was no one available to discharge you. The Plan
denied your request. The Plan says that the copayment you are being charged is correct.

The Plan must follow Medicare rules. Medicare rules say that the day of discharge, death, or a day on which a
patient begins a leave of absence is not counted as a day unless discharge or death occur on the day of
admission.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of SNF care have been met. Specifically, the record indicates that the Plan applied a copayment for
the date of service that you were discharged from the SNF. The contract with the Plan does not state that a
copayment would apply to the day of discharge. The copayment applied in this case is not appropriate.
Therefore, we decided that the Plan has to waive the copayment for skilled nursing facility (SNF) care provided
on February 8, 2021.

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.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 24-hour private duty nursing services for the enrollee.

You asked the Plan to pre-approve private duty nursing services. You say that the requested nursing services
are medically necessary. The Plan denied your request. The Plan says private duty nursing services are not
covered. Maximus overturned the Plans denial based on medical necessity. The Plan states the argument was
not medical necessity but that unfortunately the private duty nursing services are not covered.

The Plan noted that they approved, on initial review, private duty nursing services in the home 8 hours a day
for four weeks (28 days) for a total of 224 hours from May 2, 2021 to May 29, 2021; then 4 hours a day for 4
weeks (28 days) for a total of 112 hours 5/30/21 to 6/26/21. The Plan states that private duty nursing services in
the home 24 hours per day 7 days per week were denied as non-covered.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not cover 24-hour private
duty nursing services. The Plan contract does not cover private duty nursing services. The argument is not
medical necessity but the fact that the requested 24-hour care is not covered. Therefore, we decided the Plan
does not have to pre-approve 24-hour private duty nursing services for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 12, 2021.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on January 4, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on January 12, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 18, 2021.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on January 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on October 22, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the drug testing. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for the drug testing provided on October 22, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on January 5, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the rest home visit. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the rest home visit provided on January 5, 2021 by an out of network (OON) provider