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

We decided that the Plan does not have to waive the copayment for emergency care provided from September 12, 2020, to September 15, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges because you were admitted to the hospital. 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 $50 copayment for emergency care. The medical records show that you were admitted under observation after receiving emergency care from September 12, 2020, to September 15, 2020. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided from September 12, 2020, to September 15, 2020.
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 you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 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. Your medical conditions are stable. There are no medical needs requiring inpatient admission. 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home ventilator (CPT Code E0466RR).
You asked the Plan to pre-approve the home ventilator. You say that the enrollee was in the hospital on January
24, 2021, where they almost died. You state you were told by the doctors in the hospital that the enrollee would
need a trilogy ventilator system at home because their condition has not improved with a BiPAP machine. The
Plan denied your request. The Plan says based on the clinical information provided to the Plan, the enrollee
tolerates a BiPAP device and there is no clinical indication for a home ventilator. 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 home ventilator. Our physician
reviewer found based on the medical records provided there is not sufficiently detailed information that the
enrollee meets the requirements listed in the LCD L33800 for Medicare coverage. Records do not document
failure of a BiPAP system for the enrollee; hospital records indicate improvement in their condition was
achieved with use a of a BiPAP system after adjustments were made by a pulmonary consultant.
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 home ventilator have not been met. Therefore, we decided that the Plan does
not have to pre-approve home ventilator (CPT Code E0466RR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group 2 powered operated vehicle (K0842).
You asked the Plan to pre-approve the group 2 powered operated vehicle. You say that you need a new motor scooter for longer distances. The Plan denied your request. The Plan says this is a duplicate request for an item you already have.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The rules also state that for equipment to be covered, it must be appropriate and needed for use inside the home. The file shows that you have group 2 powered operated vehicle. This vehicle serves the same purpose as the group 2 powered operated vehicle. In addition, the request for longer battery life is for use outside of the home. Although a longer battery life may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve the group 2 powered operated vehicle (K0842).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from August 10, 2020, through
September 15, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the member has no out of network benefits and the services were not plan directed.

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 physician's services. 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 physician's services provided from August 10, 2020, through September 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated ankle-foot orthosis (L1970, L2275,
L2820, L2220) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the physical exam documentation does not show documented failure of a prefabricated
splint.

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 enrollee notes no change in her pain with use of the boot. Exam reveals pain on palpation of the
posterior tibial tendon from the medial malleolus to the navicular still present. Range of motion of the subtalar
and talonavicular joint are intact. There is pain and difficulty with heel rise. She has a pes planus foot structure
on standing exam. Valgus heel on standing exam. Strength is 4/5 bilateral lower extremity muscle groups due
to pain and deformity. MRI of the right ankle is noted to show posterior tibial tendinosis, without tear or
hindfoot arthritis present. X-rays of the right foot are noted to show talar head uncovering, enlarged navicular;
decreased calcaneal inclination. However, there was no documentation of any abnormalities that would indicate
a need for a custom brace. The exam does not specifically documentation special testing to demonstrate the
integrity of the ankle ligaments and tendons with regard to potential instability. There is limited documentation
showing trial/failure of any off-the-shelf braces/prefabricated splint. Therefore, the custom fabricated orthosis
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a custom fabricated ankle-foot orthosis (L1970, L2275, L2820, L2220) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy services to be provided by the out-of-network provider.

You asked the Plan to pre-approve the psychotherapy services. You say that you have had a long history of mental health and substance abuse challenges that include numerous psychiatric hospitalizations for chronic depression and suicidal thoughts. You say that you depend on your mental health providers to see you weekly and you have been receiving excellent care from this provider. The Plan denied your request. The Plan says there is no medical necessity for continued treatment with an out-of-network provider.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve psychotherapy services to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan does not have to pre-approve electroretinography (0509T) for the enrollee.
You asked the Plan to pre-approve electroretinography (0509T). You say that this treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. We overturned the Plans denial. The Plan requested a reopen and stated that we did not apply the correct LCD criteria.
Our Medical Director reviewed the case file and the reopen request. Our Medical Director had the medical records reviewed a second time. This review states multiple office visit notes and imaging studies from December 22, 2016 to February 26, 2020 were reviewed. The medical records show the enrollee had history of open angle glaucoma. The examinations during this period documented numerous dilated evaluations of the optic disc, as well as optical coherence tomography of the nerve-fiber layers and optic discs. The optic discs were consistently evaluated as having cup-disc ratio of 0.1 right eye and 0.3 left eye, with bilateral peri-papillary atrophy. At no time was optic atrophy found on examination. Because there was no optic atrophy found on examination, and no suspicion of glaucomatous optic atrophy identified in the record, the documentation does not confirm that the enrollee has been diagnosed with Glaucomatous Optic Atrophy. In addition, there are no findings on examination or ancillary testing that would suggest that diagnosis. Medicare coverage criteria for electroretinography 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 electroretinography (0509T) have not been met. Therefore, we decided that the Plan does not have to pre-approve electroretinography (0509T) for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan does not have to waive the $2.31 cost share charged for administration of Part B Drugs on October 2, 2020.

You asked the Plan to waive this cost share. You say that you do not believe this $2.31 is correct. The Plan denied your request and states this cost share was included in the administration of this Part B drug. Maximus overturned the Plans denial stating this was coded as a medical supply and should be no charge. The Plan requested a reopen and stated that this cost share is included as part of the supply or service for administration of this drug and was billed correctly by the provider.

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 10% coinsurance for Medicare Part B drugs, which would include supplies or items needed for administration that are billed appropriately by the provider. 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 $2.31 cost share charged for administration of Part B Drugs on October 2, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan does not have to waive or reduce the cost share charged for cataract eye surgeries with placement of intraocular lenses (V2632) and aqueous shunts (L8612) provided on July 22, 2020 and July 28, 2020.

You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost share was charged based on the services provided and the Plan contract agreement. Maximus overturned the Plans denial stating the contract was ambiguous. The Plan requested a reopen and stated that page 61 of the Plan contract indicates there could be a charge for prosthetic items provided during cataract surgery.

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. Your contract with the Plan clearly says that a 20% coinsurance is applied to prosthetic supplies and this could include items provided during cataract surgery. These supplies and services were provided during an outpatient procedure for the treatment of cataracts. The costs incurred were paid based on the claim submitted by your provider. 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 cost share charged for cataract surgery provided July 22, 2020 to July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the filling (D2332) provided on January 27, 2020.

You asked the Plan to reimburse you for the filling. You say that you did not submit the claim because you
were not aware that you had dental coverage. You say that you should be reimbursed for what you would have
paid at the time you received the services. The Plan denied your request. The Plan says fillings are not listed as
a covered service.

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 reimburse you for
the filling (D2332) provided on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 3, 2019 and October 15, 2019.

You asked the Plan to pay for the physician services. You say that you thought the Plan would pay a portion of the charges. The Plan denied your request. The Plan says this physician 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 the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the physician services provided on September 3, 2019 and October 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for removal of recurring cataract in lens capsule using laser (66821) provided September 9, 2020.

You asked the Plan to waive the copayment for the outpatient cataract surgery services. You say that you was not informed that you would be responsible for any amount of this procedure. This has caused you great stress financially. 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 $300 copay for outpatient surgery services. 

You have been asked to pay $300 copay for the outpatient cataract surgery services. The outpatient cataract surgery services fall within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 removal of recurring cataract in lens capsule using laser (66821) provided September 9, 2020.
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 the enrollee's ongoing skilled therapy and nursing needs can be provided at at home with home health care, or in a long-term care setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 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 pelvic and humerus fractures after a fall. Your medical conditions are stable. There are no medical needs requiring inpatient admission. 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that 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 the enrollee's 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F2 gene analysis and F5 gene analysis testing.
You asked the Plan to pre-approve F2 gene analysis and F5 gene analysis testing. 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 F2 gene analysis and F5 gene analysis testing are non-covered unless the enrollee is pregnant. We looked at the file and Medicare rules. Review of the file does not support that the enrollee is pregnant. Based on this information, we decided that Medicare rules for coverage of F2 gene analysis and F5 gene analysis testing have not been met. Therefore, we decided that the Plan does not have to pre-approve F2 gene analysis and F5 gene analysis testing.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that the enrollee is not able to stand or walk.
The Plan denied your request. The Plan says the enrollee does not have skilled nursing or therapy needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
Continued SNF services beyond February 18, 2021, were requested. 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 continued services. Our physician reviewer found that from a nursing
perspective, the enrollee received oral medications, had stable vital signs, and had uncomplicated wound care.
There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a maximal
assist level with bed mobility and transfers. He required varying assist with activities of daily living. There are
no identifiable skilled therapy service needs. He does not require skilled nursing or therapy services on a daily
basis. He does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued skilled nursing facility (SNF) services.