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

We decided that the Plan does not have to pay for the emergency department visit (99282) pulse oximetry (94760) infectious agent antigen detection by immunoassay technique (87426) provided January 29, 2021.

You asked the Plan to pay for the emergency services. You say that please reconsider these claims as they are much too expensive, and you were not expecting this. The Plan denied your request. The Plan says the plan cannot pay a provider who is not eligible to participate in Medicare.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Medicare does not certify freestanding emergency rooms or recognize them as departments since they cannot demonstrate compliance with hospital Conditions of Participation (COP). Therefore, independent freestanding emergency rooms cannot accept Medicare or receive Medicare reimbursement.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99282) pulse oximetry (94760) infectious agent antigen detection by immunoassay technique (87426) provided January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pest control services (S5165).
You asked the Plan to pre-approve pest control services. You say that you are appealing the denial for the requested pest control services The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage under the Essential Extras benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. In this case, supporting documentation is required from the physician that shows that you have a covered condition, and you would benefit from having routine pest control services in your current home. Multiple attempts were made to obtain medical records without success. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pest control services have not been met. Therefore, we decided that the Plan does not have to pre-approve pest control services (S5165).
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 IRF care is medically necessary. The Plan denied
your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial
because medical records were not submitted with the appeal. The Plan requested a reopen and provided the
required medical records.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for inpatient
rehabilitation facility (IRF) services. Based on the medical records provided, the documentation does not
support that the complexity of the nursing, medical and rehabilitation needs required an acute hospital inpatient
stay in an IRF. The documentation also does not support there was a need for at least 3 hours a day for 5 days a
week, or 15 hours over 7 consecutive days, of therapy services. A lower level of care was appropriate.
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 provide additional payment for the determination of refractive state (92015) provided December 22, 2020, by an out-of-network (OON) provider.

You asked the Plan to provide additional payment for the eye refraction. You say that the exam should be covered. The Plan denied your request. The Plan says this claim has been processed and paid up to the Plan's allowed amount. Since you used a provider who is not contracted with the Plan's third-party vision vendor, you are responsible for the amount charged by the provider above the allowed amount.

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. The Plan covers routine eye exams including refraction up to $75. When using an OON provider you are responsible for any costs above the Plan approved amount. 

We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the Plan's third-party vision vendor. The Plan has provided payment up to the $75 allowed amount for routine eye exams. Therefore, we decided that the Plan does not have to provide additional payment for the determination of refractive state (92015) provided December 22, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220), gingival irrigation (D4921), retainer crowns (D6740 x2), pontic (D6245), and an extraction (D7210) provided from March 9, 2021, through March 16, 2021.
You asked the Plan to pay for a limited oral evaluation, an intraoral periapical radiographic image, gingival irrigation, retainer crowns, pontic, and an extraction. You say that the services at issue were necessary, and you were not aware they would not be covered. 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 a limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220), gingival irrigation (D4921), retainer crowns (D6740 x2), pontic (D6245), and an extraction (D7210) provided from March 9, 2021, through March 16, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for BRCA genetic testing provided on March 12, 2021.

You asked the Plan to pay for BRCA genetic testing. You say that the presence of the BRCA gene in your family members' illnesses cannot be ruled out, therefore, the basis of the Plan's denial is not valid. The Plan denied your request. The Plan says the denial of payment for this service is correct, because BRCA testing of individuals without a personal history of cancer is not covered.

The Plan must follow Medicare rules. Medicare rules say that BRCA genetic testing of individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer is non-covered. 

We looked at the file and Medicare rules. You have no personal history of a type of cancer for which BRCA genetic testing may be covered. Based on this information, we decided that Medicare rules for coverage of BRCA genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for BRCA genetic testing provided on March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a 2D oral/facial photographic image (D0350 x4) provided on March 5, 2021.
You asked the Plan to pay for a 2D oral/facial photographic image. You say that you want the Plan to pay for the service at issue. The Plan denied your request. The Plan says the services at issue is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 a 2D oral/facial photographic image (D0350 x4) provided on March 5, 2021.
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. The Plan denied your request. The Plan says you do not need an intensive rehab therapy program.
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 physician reviewer found that you were admitted to the acute care hospital for altered mental status, sepsis, rhabdomyolysis, urinary tract infection, atrial fibrillation and acute kidney injury. Your medical conditions are stable. There are no complex nursing needs. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for transluminal angioplasty provided from June 12, 2020, to June 13, 2020.
You asked the Plan to waive the copayment for transluminal angioplasty. You say that due to the quality of care you received you feel that you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received transluminal angioplasty from June 12, 2020, to June 13, 2020, at an outpatient hospital facility. Transluminal angioplasty is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $200 copayment.
You have been asked to pay a $200 copayment for transluminal angioplasty. Transluminal angioplasty falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 transluminal angioplasty provided from June 12, 2020, to June 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 6, 2020.

You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. 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 Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services on April 6, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthopedic consultation (99204) to be rendered by the out of network (OON) provider.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an orthopedic consultation (99204) to be rendered by the out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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. Our physician reviewer found the patient appears to be unstable and still requires additional short-term acute care services which can be safely administered at the current acute care facility. The patient does not require services at the LTACH that are not already available at the current facility.
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. Specifically, there are no services at
the LTACH that the patient requires that are not already available and covered at the current facility. This
means admission into a LTACH is not medically necessary. Therefore, we decided that the Plan does not have
to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for dialysis.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says the service is available in-network.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral out-of-network for dialysis.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve integrated biopsychosocial assessment (90791) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the psychiatric services. You say that you were not aware that you had to go to an in-network provider for services to be covered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Licensed Professional Counselors are not eligible for coverage of services.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve integrated biopsychosocial assessment (90791) to be provided 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 outpatient clinic visit provided on November 25, 2020 by
an out of network provider.
You asked the Plan to pay for the outpatient clinic visit. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says you did not request prior authorization.
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 service at issue in this appeal. The Plan did not pre-approve the service
at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that
the Plan does not have to pay for the outpatient clinic visit provided on November 25, 2020 by an out of
network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on March 3, 2021, by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you provided optimum care to the enrollee and should be fully compensated for the services. The Plan denied your request. The Plan says the provider is not a network provider with the Plan and services were not urgent or emergent, nor were they approved in advance.
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit (99214) provided on March 3, 2021, by an out of network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical radiographic images (D0220, D0230 x2) provided on February 8, 2021.

You asked the Plan to pay for intraoral periapical radiographic images. You say that you were told that the provider was in-network. The Plan denied your request. The Plan says the services at issue are not covered services.

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 intraoral periapical radiographic images (D0220, D0230 x2) provided on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99349) provided on September 22, 2020.

You asked the Plan to pay for the home visit. You say that you would like reconsideration because this service was billed correctly. The Plan denied your request. The Plan says the type of bill on the claim shows 711, which is not a valid place of treatment for the service rendered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT code 99349 is not supported in the record. Specifically, this service was billed on a facility claim with type of bill code 711. CPT code 99349 is for a home visit, so billing on a facility claim is not appropriate in this case.

Based on this information, we decided that Medicare rules for coverage of the home visit have not been met. Therefore, we decided that the Plan does not have to pay for the home visit (99349) provided on September 22, 2020.