Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99202) provided August 12, 2019 to November 4, 2019.
You asked the Plan to pay for the office visit. You say that you paid by credit card at the time of visit and specified benefits to be paid to you, not the provider. The plan has denied the claims multiple times. The Plan denied your request. The Plan says office visits rendered by a chiropractor is not covered under the plan benefits.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99202) provided August 12, 2019 to November 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the root canal and crown provided on June 23, 2020, and August 25, 2020.
You asked the Plan to pay more for the root canal and crown. You say that you believe these services should be covered. The Plan denied your request. The Plan says you have exceeded the benefit period program maximum.
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, you are responsible for a 50% coinsurance for Class 3 Major Services, which includes root canals. The Plan also offers an annual maximum benefit of $1,000 every year. The record shows that you met the annual maximum benefit while reprocessing your coverage for the crown provided on August 25, 2020 and your annual maximum benefit has been exhausted. The Plan is not responsible for paying more than $1,000 for covered dental services each year. Therefore, we decided that the Plan does not have to pay more for the root canal and crown provided on June 23, 2020, and August 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0667, E0651) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a pneumatic compression device. You say that this provider has the device you need. The Plan denied your request. The Plan says the requested item 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 pneumatic compression device (E0667, E0651) to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transport from residence to dialysis provided on May 06, 2020.
You asked the Plan to pay for the non-emergent ambulance transport. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee appears to be able to sit in a wheelchair or recliner therefore alternatives to transport may include a wheelchair van or a private vehicle.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. The record shows the enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. The enrollee could have been safely transported by another type of vehicle. You did not request prior authorization. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transport from residence to dialysis provided on May 06, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance rendered on July 9, 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 procedure code 77003 is not supported.
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 77003 is fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure). We find that CPT code 77003 is not supported in the medical record. Specifically, this is an add-on code that was not billed with a required primary procedure code. 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 fluoroscopic guidance rendered on July 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is at risk for readmission to the hospital for complications associated with delayed mobilization. The Plan denied your request. The Plan says the enrollee does not require an intensive therapy program with multiple visits from a rehab doctor.
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 the enrollee was admitted to the acute hospital for atrial fibrillation, shortness of breath and hypoxemia. His medical problems are stable. There are no complex nursing needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. 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 pay for genicular nerve radiofrequency ablation provided on October 29, 2020.
You asked the Plan to pay for the genicular nerve radiofrequency ablation. You say that you would like reconsideration because your provider attempted to get prior authorization without success. The Plan denied your request. The Plan says this service is experimental.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the genicular nerve radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental procedure that is the subject of on-going clinical trials. 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 genicular nerve radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pay for genicular nerve radiofrequency ablation provided on October 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration
because the inpatient services were medically necessary. The Plan denied your request. The Plan says the
member does not meet criteria for inpatient services.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the record did not show that at the time of inpatient admission the admitting
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or
observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care.
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 need IRF care. The Plan denied your request.
The Plan says rules for IRF care have not been met.
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 you were admitted to the hospital for a stroke with left sided weakness. Your medical
problems are stable. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. In addition, 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.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic treatment provided from August 17, 2020, through December 22, 2020.

You asked the Plan to pay for the chiropractic treatment. The Plan denied your request. The Plan says that the Plan will not authorize reimbursement for the cost of self-referred chiropractic services provided by a non-network provider. The member pursued non-network care without prior authorization. Additionally, member is contractually required to obtain this service from network providers.

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 chiropractic treatment. 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 chiropractic treatment provided from August 17, 2020, through December 22, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management provided on July 13, 2020.
You asked the Plan to pay for the evaluation and management service. You say that the service was necessary. 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 member'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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management provided on July 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump.

You asked the Plan to pre-approve a fluid circulating cold pad with pump, any type (E0218). You say that your doctor advised you that this is part of your recovery. The Plan denied your request. The Plan says cold therapy pumps are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. A fluid circulating cold pad with pump, any type (E0218) is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of a fluid circulating cold pad with pump, any type (E0218) have not been met. Therefore, we decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron tablets.

You asked the Plan to pre-approve Ondansetron tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Ondansetron tablets are not covered under the enrollee's Medicare Part B benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron tablets.

Benefits for Ondansetron tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee from May 26, 2020, to June 10, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says this claim denied because the provider was not eligible for payment of this service. The Plan states that the NPI Registry website shows this provider registered with a taxonomy identified as a Nurse Practitioner. The Plan states that the provider did not bill with this taxonomy. The Plan included the additional pages of the claim image that show the provider has billed with a Registered Nurse taxonomy. This is not allowed as payable under Medicare.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the claim cannot be billed due to a discrepancy with the taxonomy code billed by the servicing provider. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee from May 26, 2020, to June 10, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the oxygen concentrator.
You asked the Plan to pre-approve the oxygen concentrator. You say that you would like reconsideration because continued oxygen treatment is medically necessary. The Plan denied your request. The Plan says that the documentation does not show that the member has been re-evaluated.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 oxygen concentrator. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the oxygen saturation was less than 88% for more than 5 minutes, meeting criteria for Group I. For Group I patients, certification of oxygen need is for 12 months. 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 oxygen concentrator have been met. Therefore, we decided that the Plan has to pre-approve the oxygen concentrator.
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: 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 services required exceed the capabilities of lower levels of care. The Plan denied your request. The Plan says the enrollee does not have a complex illness that requires continued acute hospital care for more than 25 days.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for treatment of a diabetic coma and sepsis. He is presently medically stable. He does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that he requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need to be able to do normal everyday activities. The Plan denied your request. The Plan says you do not have complex rehab needs that can only be met in an IRF.
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 hospital or peripheral vascular disease and had a below the knee amputation of the left leg. Your medical problems are stable. There are no complex nursing needs. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of a portable x-ray (R0070).

You asked the Plan to pay for the transportation of a portable x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A Skilled Nursing Facility (SNF) stay, the transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation of a portable x-ray have not been met. Specifically, this claim was billed with a place of service code indicating the member was in a Part A covered stay. This service is not separately billable when the member is in a Part A covered stay. Therefore, we decided that the Plan does not have to pay for the transportation of a portable x-ray (R0070).