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

We decided that the Plan does not have to waive the copayment for an X-ray.

You asked the Plan to waive the copayment for an X-ray. You say that the service was related to COVID-19 and you thought all copayments would be waived. 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 $110 copayment for basic radiological services for outpatient hospital services.

You received an X-ray at an outpatient hospital facility. X-rays are not included in the COVID-19 waiver, therefore, you are responsible to pay your share of the cost-sharing charges.

You have been asked to pay the allowed amount of $75.48, which is less than the $110 copayment for an X-ray. An X-ray falls within the outpatient hospital 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 an X-ray.
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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower 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. 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 were admitted for surgical repair of a hip fracture after a fall and encephalopathy. Your medical problems 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. 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. 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. 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: 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 with pneumonia after recent COVID-19 infection. Her medical problems are stable and she has 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation that this 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve HLA Class II typing for narcolepsy.
You asked the Plan to pre-approve HLA Class II typing for narcolepsy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that HLA Class II typing for narcolepsy is non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HLA Class II typing for narcolepsy have not been met. Therefore, we decided that the Plan does not have to pre-approve HLA Class II typing for narcolepsy.
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 4, 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 4, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance transport provided to the enrollee.

You asked the Plan to pay for this transport. You say that the enrollee was in a full brace and bed bound and could not sit in a wheelchair. The Plan denied your request. The Plan says that Medicare coverage criteria for non-emergent ambulance transport were not met. Maximus upheld the Plans denial. After we made our decision, we found an error in the criteria used for review.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. Due to COVID-19, Medicare expanded coverage for non-emergent ambulance transport to allow coverage for physician visits. The records provided show the enrollee was unable to sit in a wheelchair due to a full leg brace and was bed bound. Based on the Medicare exception and the information in the case file, we have now decided that Medicare rules for coverage of this transport have been met. Therefore, we decided that the Plan has to pay for ambulance transport provided to the enrollee

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy (PT) services.

You asked the Plan to waive the copayments for the PT services. You say that these services should be covered 100%. The Plan denied your request. The Plan says these copayments were charged 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 physical therapy visit.

You have been asked to pay a $40 copayment for each visit for the PT services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for physical therapy (PT) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the astigmatism correcting function of intraocular lens (V2787).

You asked the Plan to pay for the astigmatism correcting function of intraocular lens. You say that you had cataract surgery performed. You were given information that the facility would charge you a fee for inserting the lens and now you're getting billed for $395 as a lens charge. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL.

While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the astigmatism correcting function of intraocular lens (V2787).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81210,
81235, 81270, 81272, 81275, 81276, 81293, 81301, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403,
81404, 81405, 81406).

You asked the Plan to pay for Guardant360 testing. You say that this was medically necessary. The Plan denied
your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. Code 81479 is used to report Guardant360
testing.

We find that CPT codes 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81276, 81293,
81301, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, and 81406 are not supported
in the medical record. Specifically, these codes are not appropriate to report Guardant360 testing. Based on this
information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore,
we decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81210,
81235, 81270, 81272, 81275, 81276, 81293, 81301, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403,
81404, 81405, 81406).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental healthcare.

You asked the Plan to waive the copayment for outpatient mental healthcare. You say that you disagree with
the charges because you feel that you should only owe a $10 copayment. 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 $35
copayment for outpatient mental healthcare.

You have been asked to pay a $35 copayment for outpatient mental healthcare. Outpatient mental healthcare
falls within the outpatient mental healthcare 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 outpatient mental healthcare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4342) and the full amount for the panoramic x-ray (D0330).

You asked the Plan to pay for the dental services. You say that you informed your dentist that you could not afford anything more than the Plan's spending limit of $1,000. You do not understand why the provider exceeded this limit and feel that your wishes were disregarded. The Plan denied your request. The Plan says that you have exhausted your annual $1,000 allowance and therefore no additional payment can be made.

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 have exceeded the Plan's $1,000 maximum allowance. According to the contract, you are responsible for any charges that exceed the allowed amount. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4342) and the full amount for the panoramic x-ray (D0330).

Your complaint about services provided beyond the Plan's spending limit by a Plan-contracted provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor supplies (K0553, K0554).

You asked the Plan to pay for the continuous glucose monitor supplies. You say that the services requested were medically necessary. The Plan denied your request. The Plan says there is no evidence of an established relationship between the provider and the member.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. There are no medical records which document the patient's medical history. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor supplies (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Optune Lua electrical stimulation device for the enrollee.

You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the documentation fails to indicate that the member has Glioblastoma multiforme.

The Plan must follow Medicare rules. Medicare rules say that the use of tumor treatment field therapy for any indications other than newly diagnosed Glioblastoma multiforme will be denied as not reasonable and necessary. 

We looked at the file and Medicare rules. The file indicates that the Optune Lua is not being requested for the treatment of newly diagnosed Glioblastoma multiforme. Therefore, we decided that the Plan does not have to pre-approve an Optune Lua electrical stimulation device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay.

You asked the Plan to waive the copayment for the inpatient stay. You say that you are unhappy to receive a bill from 2019 and wonder if you are being overcharged. The Plan denied your request. The Plan says the copayment 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 $225 copayment per day for days 1-7.

You have been asked to pay a $900 copayment for the inpatient stay. ($225/day x 4 days = $900). The inpatient 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 for the inpatient stay.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chiropractic treatments.

You asked the Plan to waive the copayment for chiropractic treatments. You say that you were informed your
treatment plan was covered by the Plan. You say that you are on a fixed income and would not let the cost
build up. 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 $20
copayment for each in-network specialist's office visit for chiropractic services.

You have been asked to pay a $20 copayment for each chiropractic treatment. The total amount you owe is
$240 ($20/visit x 12 visits = $240). Chiropractic treatments fall within the "Chiropractic services (Medicare Covered)"
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 chiropractic treatments.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (G0299).

You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says a corrected claim is needed.

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 code G0299 is not supported in the medical record. Specifically, the claim was not originally filed on form CMS-1450. This is required for Home Health claims. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services (G0299).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility services billed with code FFXF.

You asked the Plan to pay for the SNF services as billed. You say that these services were medically necessary and have been correctly billed. The Plan denied your request. The Plan says that the HIPPS code billed does not match the exact HIPPS code which was authorized. There is not sufficient documentation to support code FFXF over the approved FDXF HIPPS code. A new authorization must be requested, or the claim can be corrected to the authorized HIPPS code.

The Plan must follow Medicare rules. Medicare rules say that SNF services are paid under the SNF PDPM PPS. Under this system, each digit of the HIPPS code corresponds to a different case-mix group aspect of the SNF care provided.

We looked at the file and Medicare rules. The Plan's denial is based on the HIPPS code being incorrect. Prior authorization was provided for HIPPS code FDXF, but FFXF was billed. Per review of the rules, it would be reasonable for the HIPPS code that is ultimately billed to differ from that which was first approved depending on changes during the course of the SNF stay.

The issue here is whether the patient falls into SLP case-mix group SD or SF. We find that there is sufficient evidence in the medical records to support that SF is the correct SLP case-mix group. Throughout the record it is recorded that the enrollee has a swallowing disorder and that he has been put on a mechanical soft/ground diet. Since both of these conditions are present, case-mix group SD is not appropriate. The pre-approved HIPPS code FDXF is not correct based on the findings during the SNF stay. Based on this information, we decided that Medicare rules for coverage of the SNF services as billed have been met. Therefore, we decided that the Plan has to pay for the skilled nursing facility services billed with code FFXF.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are consistently ambulating more than 100 feet. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.