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

 
We decided that the Plan does not have to pay for the post stabilization inpatient care provided to the enrollee 
from 8:01 PM on February 22, 2020 through February 24, 2020. 
 
You asked the Plan to pay for the post stabilization inpatient care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that the enrollee was stable for transfer. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 the post stabilization inpatient care. Our 
reviewer says that the post stabilization care was not medically reasonable and necessary for the enrollee in this 
case. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient 
was not stable for transfer on any dates of service. Our physician reviewer found that the enrollee was 
hemodynamically stable for ambulance transport to a Plan 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 post stabilization inpatient care have not been met. Therefore, we decided 
that the Plan does not have to pay for the post stabilization inpatient care provided to the enrollee from 8:01 
PM on February 22, 2020 through February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 8, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the documentation 
did not support the testing was performed with blood sampling. 
 
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 looked at the file and the rules. The material for examination is whole blood, serum, plasma, or 
cerebrospinal fluid. We find that the lab services at issue are not supported in the medical record. Specifically, 
the records do not indicate that a blood sample was provided for the testing services. Based on this information, 
we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on April 8, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the right upper extremity 
joint without dye (73221). 
 
You asked the Plan to pre-approve this service. You say that an MRI of the right upper extremity joint is 
medically necessary for the enrollee. The Plan denied your request. The Plan says that an MRI of the right 
upper extremity joint is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 this service. Our reviewer says that an 
MRI of the right upper extremity joint is medically necessary. Our physician reviewer found that the patient 
has a possible rotator cuff injury of the shoulder. An MRI is both reasonable and necessary for a diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the right upper extremity joint without dye (73221).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray of hip with pelvis (73502) provided on December 
12, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the X-ray of hip with pelvis. You say that your primary physician did submit a 
referral for this service. The Plan denied your request. The Plan says a referral must be obtained in advance; 
therefore, services have been denied. 
 
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 has network providers 
available who can provide 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 X-ray of hip with pelvis (73502) provided on 
December 12, 2019, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ExoDx Prostate Intelliscore (EPI) testing rendered on May 22, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were not medically necessary.The Plan must follow Medicare rules. Medicare rules say that EPI testing 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has elevated prostate specific 
antigen (PSA) levels. The documentation is insufficient to demonstrate that the coverage criteria for EPI testing are met. Such factors as digital rectal exam, risk factors for prostate cancer, life expectancy, and persistence of elevated PSA are not sufficiently documented. The documentation does not support that the testing was reasonable and 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 pay forthe ExoDx Prostate Intelliscore (EPI) testing rendered on May 22, 2020. LCD L35396 referenced by the Plan is notrelevant for the services at issue and was not used in the MAXIMUS determination
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forresin-based composite -two surfaces, posterior (D2392), periodic oral evaluation (D0120), and prophylaxis -adult (D1110) provided on August 6, 2020, and August 11, 2020.You asked the Plan to pay forresin-based composite, periodic oral evaluation, and prophylaxis. You say that the services should be covered.The Plan denied your request. The Plan says they will not reimburse for charges incurred by Medicare Opt Out providers.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 forresin-based composite -two surfaces, posterior (D2392), periodic oral evaluation (D0120), and prophylaxis-adult (D1110) provided on August 6, 2020, and August 11, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe echocardiography (CPT Code 93306).You asked the Plan to pay forthe echocardiography. You say that the testing is necessary.The Plan denied your request. The Plan says the Medicare rules have not been 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 pay for the echocardiography. Our physician reviewer found the review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage.We lookedat this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the echocardiography have not been met.Therefore, we decided that the Plan does not have to pay forthe echocardiography (CPT Code 93306).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plandenied your request. The Plan says the stay 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approveLTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe oncology (prostate) gene expression profile services coded 0005U provided on June 25, 2020.You asked the Plan to pay forthe oncology (prostate) gene expression profile services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that oncology gene expression profile services identified with code 0005U are non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oncology (prostate) gene expression profile services have not been met.Therefore, we decided that the Plan does not haveto pay forthe oncology (prostate) gene expression profile services coded 0005U provided on June 25, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator provided from February 28, 2020, through April 28, 2020.You asked the Plan to pay for the oxygen concentrator. The Plan denied your request. The Plan says prior authorization is required from the Plan for this disputed service to be covered. 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 incases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider withthe Plan. The Plandid not pre-approve the item at issue. We found no exception that would require the Planto pay for these items. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator provided from February 28, 2020, through April 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF 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 above.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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for aphasia, ataxia and dysarthria. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. Thepatient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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.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-approveacute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diagnostic eye exam with ophthalmologist (92014) provided on August 4, 2020 by an out of network (OON) provider.You asked the Plan to pay fordiagnostic eye exam. You say that you provided medically necessary services in good faith.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 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 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 forthe diagnostic eye exam with ophthalmologist (92014) provided on August 4, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on June 17, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
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 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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on June 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation. 
 
You asked the Plan to pre-approve additional trips. The Plan denied your request. The Plan says only 24 trips 
are covered per year. 
 
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 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the requested additional trips will exceed the Plan maximum benefit for coverage of routine transportation. 
Therefore, we decided that the Plan does not have to pre-approve additional trips for routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for durable medical equipment provided by a 
participating provider on April 7, 2020. 
 
You asked the Plan to waive the copayment for durable medical equipment. You say that you did not wear the 
equipment. You say that you ended up returning it. The Plan denied your request. The Plan says the correct 
coinsurance has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $321.65. The total amount you are being asked to pay is $64.33 ($321.65 x 20% = 
$64.33). Durable medical equipment falls within the durable medical equipment 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 durable medical equipment provided by a participating provider on 
April 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited bilateral noninvasive physiologic studies of upper or 
lower extremity arteries (93922) provided October 28, 2019. 
 
You asked the Plan to pay for the extremity arterial studies. You say that the claim has not been paid in full or 
under the terms of the contract for the services provided to this enrollee. 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. 
 
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 limited bilateral noninvasive physiologic studies of upper or 
lower extremity arteries (93922) provided October 28, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 82565) provided on June 11, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this is a column II code.The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure code 82565 is part of an edit pair with procedure code 80053. Procedure code 80053 is a column one code, and procedure code 82565 is a column two code. Procedure code 80053 has been billed for this date of service, which means that procedure code82565 is not eligible for payment.Therefore, we decided that the Plan does not have to pay forthe services (CPT 82565) provided on June 11, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided from August 6, 2020, through August 12, 2020, by an out-of-network provider.You asked the Plan to pay forthe laboratory services. You say that you went to see your doctor who is in-network, the doctor took a tissue sample and sent to a provider that is not in-network, but you were not notified.The Plan denied your request. The Plan says the doctor that referred you to this provider does not participate with the Plan. The Plan states this provider is also not participating with your plan, the services were not referred by a network provider and the 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 providersavailable 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 forthe laboratory services provided from August 6, 2020, through August 12, 2020, by an out-of-network provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay on March 3 to March 4, 2020.You asked the Plan to waive the copayment foran inpatient hospital stay.You say that the total amount should have been paid between insurance of Medicare and the Plan.The Plan denied your request. The Plan says the correct copayment was applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $375 copayment for each day of days 1-5 of a covered hospital stay. You have been asked to pay a $375 copayment for a 1-day inpatient hospital stay. An inpatient hospital 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 foran inpatient hospital stay on March3 to March 4, 2020.