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

We decided that the Plan does not have to pay for the inpatient services billed with DRG 193 provided from
September 29, 2019, to October 2, 2019.

You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with A41.9 (sepsis, unspecified organism). 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 inpatient services. Our reviewer says that the
documentation does not support the billing of DRG 193. Our physician reviewer found the enrollee was
admitted for pneumonia. A diagnosis of anemia secondary to black stools is documented, was administer 2
units of red blood cells. Physician documented that hypotension was related to hypovolemia and lactic acid
improved. Blood cultures were negative. There is no documented baseline for creatinine. An elevated
creatinine in the setting of CKD is considered direct organ dysfunction. The review has determined that the
documentation does not support the use of DRG 193. Principal diagnosis code assignment of A41.9, Sepsis,
unspecified organism. Therefore, the services are not payable as billed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient services billed with DRG 193 provided from September 29, 2019, to October 2, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 11, 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 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 services provided by an out-of-network provider on December 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 14, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 services provided by an out-of-network provider on October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on January 7, 2021.

You asked the Plan to pay for periodontal maintenance. You say that you understand this is not a covered benefit, but you want the Plan to adjust the charges. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on January 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the dispensing Plan meets for Part D coverage, and the pharmacy dispenses the drug to the enrollee to self-administer, or to take it to the provider.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia.

Benefits for Prolia 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Radiofrequency Ablation (RFA).
You asked the Plan to pre-approve destruction by neurolytic agent, facet joint (64635LT) and destruction by neurolytic agent each additional facet joint (64636LT). You say that you are in a lot of pain and need Radiofrequency Ablation. The Plan denied your request. The Plan says the record does not show that you have had 2 diagnostic MBBs.
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 destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635LT) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (64636LT). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee never had the required 2nd set of diagnostic MBBs. The enrollee had sacral branch RFAs. The Left side RFA must be proceeded by diagnostic MBBs and sacral branch RFA are considered experimental/investigational and are 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 destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging
guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635LT) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (64636LT) have not been met. Therefore, we decided that the Plan does not have to pre-approve Radiofrequency Ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair (E0240).

You asked the Plan to pre-approve a shower chair. You say that you need this due to your balance issues. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the emergency and inpatient services provided from August 24, 2020, and August 28, 2020.

You asked the Plan to waive the copays for the services provided. You say that the services were horrible. The Plan denied your request. The Plan says the claim processed 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).

The file shows you received emergency room services. You have been asked to pay a $90 copay for the services provided. The services fall within the emergency care benefit category. You also received 4 days of inpatient hospital care. A $250 copay was applied per day, totaling $100. The services fall within the inpatient hospital care benefit category. Copays are not determined by the quality of care you receive. 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 copays for the emergency and inpatient services provided from August 24, 2020, and August 28, 2020.

Your complaint about horrible service 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on April 11, 2020.

You asked the Plan to pay for periodontal scaling and root planing. You say that this service is a cleaning and should be covered. The Plan denied your request. The Plan says the service you were provided on the date in question is periodontal scaling and root planing, which is not the same as a standard (prophylaxis) cleaning. This service is not covered by Medicare or by the Plan's supplemental dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on April 11, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the acupuncture services you received on July 2, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the benefit limit has been reached.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not submitted documentation showing that the benefit limit has been reached for acupuncture services. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the acupuncture services you received on July 2, 2020.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an implantable joint device (C1776) provided on July 22, 2020.
You asked the Plan to waive the coinsurance for an implantable joint device. You say that the item in question has been miscategorized. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for each Medicare-covered prosthetic or orthotic device and related supplies. You have been asked to pay $879.96, or less than 20% of the Medicare-allowed amount of $13,633.66, for an implantable joint device. An implantable joint device falls within the "Prosthetic Devices and Related Supplies" benefit category. This means that you have been asked to pay less than or equal to 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 coinsurance for an implantable joint device (C1776) provided on July 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Privigen Intravenous Immune Globulin (IVIG).
You asked the Plan to pre-approve Privigen Intravenous Immune Globulin (IVIG). You say that this drug 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 Privigen IVIG. The Plan argues that Maximus overturned in error. The Plan argues that your diagnosis is autoimmune small fiber neuropathy, and that this diagnosis is not an indication for IVIG. The medical records show you have a listed diagnosis of "Polyneuropathy, unspecified." The Neurology Outpatient Preliminary Report dated January 7, 2021 documents you have autoimmune small fiber neuropathy diagnosed via skin biopsy and positive LGL-1 antibodies. You were treated with IVIG infusions every 8 weeks and they have been helping. However, the Plan is correct in this case. The documentation does not support that you have a diagnosis for which Medicare provides coverage for IVIG, per LCD L35093. Medicare coverage criteria, therefore, are 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 Privigen Intravenous Immune Globulin (IVIG) have not been met. Therefore, we decided that the Plan does not have to provide coverage for Privigen Intravenous Immune Globulin (IVIG).
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 still require extensive hands-on assistance. The Plan denied your request. The Plan says you do not require an intensive, complex, multidisciplinary approach to daily therapy.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that you were admitted to the acute care hospital for pneumonia. Your medical problems are stable. There are no complex nursing needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removal of an impacted tooth (D7230) and alveoloplasty in conjunction with extractions of four or more teeth or tooth spaces per quadrant (D7310) for the upper left quadrant.
You asked the Plan to pre-approve the removal of an impacted tooth and alveoloplasty. The Plan denied your request. The Plan says the removal of an impacted tooth is not a covered benefit. The Plan also says that the alveoloplasty in conjunction with extractions cannot be approved because tooth #'s 10 and 14 have already been approved for extractions, and are within the same quadrant.
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. The Plan covers the alveoloplasty when the services are medically necessary and reasonable. 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 alveoloplasty. Our reviewer says that the alveoloplasty in conjunction with extractions (D7310) is not medically reasonable and necessary for the enrollee. Our physician reviewer found tooth #'s 10 and 14 have been treatment planned and approved for surgical extractions (D7210). Our reviewer found that the Plan specifically disallows for alveoloplasty (D7310) where there is surgical extraction in the same quadrant, in this case the upper left. Our physician reviewer also found that given the specific Plan limitation there would be no necessity for the requested procedure as criteria has not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the removal of an impacted tooth and alveoloplasty have not been met.
Therefore, we decided that the Plan does not have to pre-approve a removal of an impacted tooth (D7230) and alveoloplasty in conjunction with extractions of four or more teeth or tooth spaces per quadrant (D7310) for the upper left quadrant.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 12, 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 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 services provided by an out-of-network provider on November 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bilateral brachioplasty procedure.
You asked the Plan to pre-approve the requested services. You say that the rubbing of your arms causes irritation and sores. The Plan denied your request. The Plan says the services are cosmetic in nature.
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 requested services. Our physician reviewer found that in this case, you underwent gastric bypass surgery resulting in weight loss. The provided documentation does not indicate that there is functional limitation, nor do the photographs support chronic rashes. The provider has indicated that the requested procedure is cosmetic in nature. Therefore, the requested services 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a bilateral brachioplasty procedure.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit (99284) and urgent care center services (S9083) provided December 11, 2020.
You asked the Plan to waive the copayment for the urgent care and emergency services. You say that you went to the urgent care for treatment and was told that an ultrasound was needed but the facility was not equipped with one. You then immediately went to a local ER. No treatment was provided at the urgent care. 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 $90 copay for emergency care and $45 copay for each urgent care facility visit. You have been asked to pay $135 (90 + $45) for the urgent care and emergency services. The urgent care and emergency services falls within the Emergency care and Urgently needed 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 the emergency department visit (99284) and urgent care center services (S9083) provided December 11, 2020.