Persius/hicric huggingface dataset:
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 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 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 medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rybelsus.
You asked the Plan to pre-approve Rybelsus. You say that Rosuvastatin was not effective. The Plan denied
your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Rybelsus.
Benefits for Rybelsus 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210), and the comprehensive oral evaluation (D0150) received November 17, 2020 from the non-participating dental provider.
You asked the Plan to pay for the dental services (D0210, D0150). You say that the Plan has always paid 100% of the cost for dental services. The Plan denied your request. The Plan says the requested payment for dental services exceeds what is covered under your 2020 supplemental 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 either are not among those covered under this benefit or in excess of what is covered by the Plan. The Plan covers a complete series of intraoral x-rays once every 36 months. The Plan has submitted evidence that you last received this service February 25, 2019, therefore this service is not eligible for coverage.
The provider in this case is out-of-network. The Plan contract says you can get care from an out-of-network dental provider, but you may pay more for covered services. In this case, the Plan has agreed to cover 100% of the cost of the allowable amount for the comprehensive oral evaluation (D0150). You have been asked to pay the difference between the Plan's allowable amount and what the out-of-network provider charged. Therefore, we decided that the Plan does not have to pay for the intraoral - complete series of radiographic images
(D0210), and the comprehensive oral evaluation (D0150) received November 17, 2020 from the non-participating dental provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and a pneumatic appliance (E0673) provided on February 3, 2021.
You asked the Plan to pay for a pneumatic compression device and a pneumatic appliance. You say that the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that a pneumatic compression device and a pneumatic appliance was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and a pneumatic appliance (E0673) provided on February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection.
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says there is no documentation of conservative management for the current episode of pain.
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 pre-approve the injection. Our physician reviewer found that you have chronic neck pain. You now present with cervical radiculopathy. Magnetic resonance imaging (MRI) shows a disc bulge at C6-C7 which abuts the spinal cord. There is no documentation of recent physical therapy, chiropractic therapy, or other conservative therapy. Therefore, the requested injection is not medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by the out of network (OON) provider on November 16, 2020 and December 21, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 chiropractic manipulative treatment (98941) rendered by the out of network (OON) provider on November 16, 2020 and December 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health.
You asked the Plan to pre-approve inpatient mental health. 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 inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of April 22, 2021 forward and could have been treated in a lesser restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any aggressive behaviors. He was being cooperative and compliant. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you on January 21, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has been
opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the
services provided to you on January 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided October 8, 2020 to October 12, 2020.
You asked the Plan to waive the copayment for the inpatient services. You say that you received a bill for $1,210 for services and feel that this is an overcharge for services received The Plan denied your request. The Plan says the claim was processed, and the correct copayment was applied per the Evidence of Coverage.
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 $325 per day for days 1-5 $0 for additional hospital days. You have been asked to pay $1300 ($325 x 4 days) for the inpatient services. The inpatient services fall 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 hospital services provided October 8, 2020 to October 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the copayment charged for inpatient mental health care provided from August 11, 2020, to August 25, 2020.
You asked the Plan to waive or reduce this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the services provided and your Plan contract agreement. Maximus partially overturned the Plans denial based on the Plan contract submitted with the case file. The Plan requested a reopen and stated that the original case file sent to Maximus contained the incorrect Plan contract. The Plan submitted the correct 2020 Evidence of Coverage for review.
The Plan is correct in this case. 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 $900 copayment for each inpatient mental health admission. 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 or reduce the copayment charged for inpatient mental health care provided from August 11, 2020, to August 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a revision of breast reconstruction with tissue expander replacement for the enrollee.

You asked the Plan to provide coverage for a revision of breast reconstruction with tissue expander replacement. You say that this surgery is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for breast reconstruction surgery. The Maximus Physician Reviewer determined the procedure was reasonable and necessary. The Plan requested a reopen and argues that this request was enrollee driven to enlarge the implants for cosmetic reasons. The Plan states that the implants had not failed, but rather, the perception was that the expanders that were in place were too small.

Our Medical Director has concluded that the Plan is correct in this case. After the initial placement of the permanent silicone gel breast implants, subsequent surgeries would be considered cosmetic, as there was not a medical indication for the procedure at that time. There was no indication that the enrollee had complications such as broken or failed implants, infection, implant extrusion, or painful capsular contracture with disfigurement. Medicare coverage criteria for this procedure were not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of revision of breast reconstruction with tissue expander replacement have not been met. Therefore, we decided that the Plan does not have to pre-approve a revision of breast reconstruction with tissue expander replacement for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on May 22, 2020.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says this testing is not covered by Medicare as a screening. The IRE overturned the Plans denial stating the services were ordered by a Plan provider. The Plan requested a reopen and stated that there is no confirmation this test was ordered by a plan provider and this testing is not covered by Medicare as a screening.
The Plan is correct in this case. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Medicare does not cover the genetic testing provided as a screening. The enrollee did not have prior authorization which is required by the Plan contract both in and out of network. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on May 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance angiography of the head provided to the enrollee on August 10, 2020 and billed under Claim A.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan stated that Claim A denied because the Plan had already paid for this service under another claim. The Plan states the NPI website shows that both providers are listed as Diagnostic Radiology Specialists and both providers work within the same professional practice or group. The Plan states the correct billing of this service needed to include modifier -59 to establish a separate and distinct service was provided. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met.
Therefore, we decided that the Plan does not have to pay for magnetic resonance angiography of the head provided to the enrollee on August 10, 2020 and billed under Claim A.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says daily skilled services are no longer required.

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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you no longer qualify for SNF coverage. You do not have any documented skilled nursing needs or skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. 

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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (CPT code 92015) provided on January 7, 2021.

You asked the Plan to pay for the eye refraction. You say that this is required to determine what glasses would be best for you. The Plan denied your request. The Plan says refractive services are not covered under your benefit plan unless rendered by a routine vision care provider found in the routine vision care section of the plan's provider directory. The Plan states if your provider is a part of the routine vision care provider network, then the claim for your refraction has been misfiled, and your provider may refile it to the appropriate vision vendor.

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. 

We looked at the file and the Plan's rules. Review of the records show that you received a comprehensive eye exam and eye refraction on January 7, 2021. The services were not routine; therefore, not covered by your medical plan. Your 2021 EOC states that "Original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts. Covered services include the following when performed by a supplemental network routine vision care provider: Eye refractions during a routine exam." Therefore, we decided that the Plan does not have to pay for the eye refraction (CPT code 92015) provided on January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99284) provided on April 18, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 99284 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function". 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 services. Our reviewer says that the use of CPT code 99284 is not supported by the records provided on April 18, 2020. Our physician reviewer found that there was no detailed examination and medical decision making of moderate complexity. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (99284) provided on April 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with an electronic knee and other features.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says a request for a K3 item does not meet Medicare criteria as reasonable and necessary.

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 pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical progress reports do not support that you are a K3 ambulator given your multiple medical conditions, shortness of breath with exertion, chronic pain, residual limb condition, and significant cardiac disease.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg with an electronic knee and other features.