Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy in the home health or hospice setting,
each 15 minutes (G0151).
You asked the Plan to pre-approve the home health physical therapy visits. You say that you do not agree with
the decision due to the fact that you are very limited in your mobility and requires some assistance from
someone. You cannot properly get out of bed, walk or do your everyday activities. The Plan denied your
request. The Plan says the enrollee does not meet homebound status as defined by Medicare. The requested
physical therapy services are medically necessary but can be provided in an outpatient facility setting, which
has been approved.
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 the home health physical therapy visits.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found the documentation does not support that the enrollee requires in-home
skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The
documentation does not support that the enrollee is homebound. The requested home health services are not
medically necessary as the enrollee can receive services on an outpatient basis.
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 home health physical therapy visits have not been met. Therefore, we
decided that the Plan does not have to pre-approve physical therapy in the home health or hospice setting, each
15 minutes (G0151).
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 the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an
IRF 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 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: 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 would benefit from the intensive rehabilitation program to return to your original level of function. You are rapidly deteriorating and can no longer ambulate at the skilled nursing facility. You say your rehab is mostly stretching and you would like a more intense program. The Plan denied your request. The Plan says the requested IRF services are not medically necessary. Records do not support the need for an intensive rehabilitation therapy program consisting of at least 3 hours of therapy per day at least 5 days a week and based on your current medical stability and lack of complexity, there is no need for physician supervision at least 3 times per week.
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 that 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 do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. 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. Medically necessary services can be provided in a different 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 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: 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 feel these services will give you the best chance for you to recover and regain your previous physical condition. The Plan denied your request. The Plan says that you can receive the care you need at a skilled nursing facility.
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 have a past medical history of diabetes,
congestive heart failure, hypertension, neuropathy, obesity and is living at home with increasing gait problems and weakness. 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 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive procedure (D9999) provided on January 21,
2020.
You asked the Plan to pay for the adjunctive procedure. You say that you have a $2,000 limit for dental
services. The Plan denied your request. The Plan says charges for dental services are excluded from coverage
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
adjunctive procedure (D9999) provided on January 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the extremity study provided on December 7, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the extremity study. You say that you would like reconsideration because you do not submit prior authorizations before rendering service. The Plan denied your request. The Plan says the service was not billed as emergent care and an attempt to obtain prior authorization was not made.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the extremity study provided on December 7, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergent transportation by a taxi (A0100).
You asked the Plan to pre-approve the additional trips. You say that you do not have any other means of transportation. You also say that the trips provided through the benefit are essential for you to get to and from your appointments in your current condition. The Plan denied your request. The Plan says 20 one-way trips are covered per plan year. The Plan also says that the maximum number of trips has been reached.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of up to 20 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional non-emergent transportation by a taxi (A0100).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on February 11, 2021.
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 services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 71045 (chest x-ray) and 32555 (thoracentesis with imaging guidance). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 32555. Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on February 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 13, 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 services are not covered.
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 codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical record. Specifically, the records show that the services were not performed on blood testing. 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 laboratory services rendered on April 13, 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 disagree with the denial. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for ataxia, cerebellar degeneration and a fall. She is now medically stable with no complex nursing or rehabilitation needs. She does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. She may benefit from further therapy
but does not require an intensive therapy program in an IRF. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services and eyewear provided by a commercial retail store not affiliated with the Plan on September 4, 2020.
You asked the Plan to pay for self-referred out of network vision services. You say that you used a provider other than the one recommended because the overall cost for the eyewear was lower. The Plan denied your request. The Plan states you were specifically referred to a Plan provider with your authorization letter dated July 15, 2020 and chose to go out of network for a supplemental benefit. Maximus overturned the Plans denial stating because Medicare does not cover vision services, the Plans contract must be specific about getting out of network care for supplemental services. The Plan requested a reopen and stated that you were well aware of the contract requirements for supplemental vision benefits and chose to use a retail provider out of network.
The Plan is correct in this case. Medicare 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. As prior authorization was requested from the Plan for vision services, and as you were provided with an approval letter and a specific provider to use, it can be inferred that you were aware of the requirement to use a specific provider to get vision services covered by the Plan but chose to self-refer to a commercial retail establishment out of network. Based on this information, we decided that the Plan's rules for coverage of vision services have not been met. Therefore, we decided that the Plan does not have to pay for vision services and eyewear provided by a commercial retail out of network provider on September 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab(88305, 88307 and 88342) provided to the enrollee on December 30, 2019and billed under Claim A. You askedthe Plan to pay forthese lab services. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen andstated that Claim A denied  becausethe provider billed with an  inappropriate diagnosis code(s). The Plan states that the provider billed diagnosis codes C50.911, C50.912, and C50.919, and these diagnosis codes all state laterality; right side, left side, or unspecified. The medical  records were specificin the use of  the  diagnosiscode for "L" and "R",  but nothing supports the "unspecified"code.The ICD-10-CM Official Guidelines for Coding and Reporting sates some ICD-10-CM codes indicate laterality,  specifying  whethera condition occurs on the left, right, or is bilateral. The guidelines stated if no bilateralcode is provided and the condition is bilateral, providers are to assign separate codes for both the left and right side. If the side is not identified in the medical record, then they are to assign the code for the unspecified side. The Plan is correct in this case. The Plan must followMedicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, Claim A cannot be paid as billed due to the omission of documentation to support the billing of the "unspecified"code. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay forlabservices (88305, 88307 and 88342) provided to the enrollee on December 30, 2019and billed under Claim A.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the bronchoscopy services provided on November 23, 2020
billed with codes 31645-51-RT and 31645-51-LT.
You asked the Plan to pay for the bronchoscopy services as billed. You say that this is correctly billed and
should be paid. The Plan denied your request. The Plan says the code at issue was billed with 2 units when the
maximum allowed per policy is 1.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 31645 is 1. This MUE has an MAI of 2. You billed 2 units of this code,
exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the
bronchoscopy services as billed have not been met. Therefore, we decided that the Plan does not have to pay
for the bronchoscopy services provided on November 23, 2020 billed with codes 31645-51-RT and 31645-51-
LT.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from January 5, 2021, through January 22, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that you had back pain and went to have physical therapy done. You say that you were informed there would be no copayment due, and you should not owe this. The Plan denied your request. The Plan says the copayments applied 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 $40 copayment for each Medicare-covered physical therapy and speech-language therapy visit. You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is $200 ($40/visit x 5 visits = $200). Physical therapy falls within the "Outpatient Rehabilitation 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 physical therapy provided from January 5, 2021, through January 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care services (T1019).
You asked the Plan to pre-approve the personal care services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the personal care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve personal care services (T1019).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on December 11, 2020.
You asked the Plan to pay for the dental service. You say that the last panoramic x-ray that you received was from a different provider, in a different specialty and location. You also say that this should be covered. The Plan denied your request. The Plan says coverage for a panoramic x-ray is limited to 1 every 3 plan years. The Plan also says that the frequency limit has been exceeded.
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 panoramic x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a panoramic x-ray that you received on December 5, 2019. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on December 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four semi-precision abutments (D6191 x4) and four semi-precision attachments (D6192 x4).
You asked the Plan to pre-approve the semi-precision abutment and semi-precision attachments. You say that you cannot afford any out-of-pocket expenses. The Plan denied your request. The Plan says these services are not covered under your benefit package.
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 four semi-precision abutments (D6191 x4) and four semi-precision attachments (D6192 x4).