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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the patient was admitted to an acute care hospital for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 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. Medically necessary care can be provided in a different level of care. Finally, there is not a reasonable expectation that this patient 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency ambulance services (A0427) and ground mileage (A0425) provided April 13, 2020.
You asked the Plan to pay for the ambulance services. You say that you are alone and needed to go to the emergency room for medical assistance. You are 70 years old and was having weakness, pain, fever from Crohn's disease and sometimes c-diff. The Plan denied your request. The Plan says based on the records the enrollee did not meet the medically necessary criteria.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found 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. Transportation could have been provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. A prudent layperson would not believe that immediate medical attention was required for an ambulatory patient who had already been evaluated/diagnosed. 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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for emergency ambulance services (A0427) and ground mileage (A0425) provided April 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hearing test provided by a participating
provider on December 7, 2020.
You asked the Plan to waive the copayment for a hearing test. You say that you were encouraged to have a
hearing test. You say that you did not know that this would have a copayment. The Plan denied your request.
The Plan says the correct copayment has been 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 a $50
copayment for hearing services/in-network.
You have been asked to pay a $50 copayment for a hearing test. The correct copayment has been applied to the
services that were provided. A hearing test falls within the hearing services/in-network 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 a hearing test provided by a participating provider on
December 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided from June 1, 2020 to June 30, 2020.
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
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 the durable medical equipment was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided from June 1, 2020 to June 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oral appliance (E0486).
You asked the Plan to pre-approve the oral appliance. You say that you are asking for reconsideration since even with the help of the plan you would have to pay another 2 thousand for the better quality mouthpiece. The Plan denied your request. The Plan says the Medicare criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this the file and Medicare rules. Medicare requires that for replacement of equipment less than 5 years old, there must be a physician's order and clinical documentation showing that the equipment is lost or irreparably damaged, or the item is worn beyond repair. The records show that you received an oral appliance (E0486) on October 30, 2020. The records do not show that the current oral appliance is lost, stolen or irreparably damaged. Based on this information, we decided that Medicare rules for coverage of the oral appliance have not been met. Therefore, we decided that the Plan does not have to pre-approve the oral appliance (E0486).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), teeth cleaning (D1110), and an intraoral complete series of radiographic images (D0210) provided on February 17, 2021.
You asked the Plan to pay an additional amount for a periodic oral evaluation, teeth cleaning, and an intraoral complete series of radiographic images. You say that you do not agree with the amount the Plan paid for the services. The Plan denied your request. The Plan says the claims for a periodic oral evaluation and teeth cleaning were processed correctly with the applicable out-of-network allowable amount paid. You are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. Intraoral complete series of radiographic images are 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, teeth cleaning, and an intraoral complete series of radiographic images have not been met. Specifically, the allowed amount of periodic oral evaluation and teeth cleaning for an out-of-network provider were paid by the plan. Any amount beyond the allowed amount is your contractual responsibility. Additionally, intraoral complete series of radiographic images are not a covered benefit. Therefore, we decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), teeth cleaning (D1110), and an intraoral complete series of radiographic images (D0210) provided on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 8, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 10, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you were informed that all copayments were being waived through the end of 2020. You say that having to pay extra bills would be a hardship and you should not be held accountable. 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 $35 copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted under Medicare rules). You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The Plan says the cost share waiver was only active through September 30, 2020. 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 office visit provided on November 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from July 6,
2020, to July 10, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that due to the treatment you
received you feel that the provider should be responsible for the charges, not you. 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 $295
copayment per admission for inpatient hospital care.
You have been asked to pay a $295 copayment for an inpatient hospital stay. An inpatient hospital 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
an inpatient hospital stay from July 6, 2020, to July 10, 2020.
Your quality-of-care concerns have been handled separately by the health plan. Medicare does not permit us to 
make a decision on this type of complaint.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for ConfirmMDx testing provided on August 31, 2020.
You asked the Plan to pay for . You say that this testing should be covered by the Plan. The Plan denied your request. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for ConfirmMDx. Maximus overturned the appeal stating the testing was shown to be appropriate. The Plan requested a reopen and stated the LCD coverage criteria were not met. The medical records show the enrollee was a 64-year-old man with an elevated PSA. A prostate biopsy was performed on August 31, 2020. ConfirmMDx was ordered. The prostate biopsy was normal. A repeat PSA in six months was planned. Our Medical Director has concluded that the Plan is correct in this case. ConfirmMDx is covered under the specific coverage criteria. The documentation does not support that the enrollee is being considered for a repeat biopsy due to persistent or elevated cancer-risk factors. Therefore, the Medicare coverage criteria 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 have not been met. Therefore, we decided that the Plan does not have to pay for ConfirmMDx testing provided to the enrollee on August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an extraction (D7210) provided on October 1, 2020.
You asked the Plan to pay for an extraction. You say that you think that the service should be covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for an extraction (D7210) provided on October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the hand-held shower head with hose (E1399) purchased on September 7, 2020.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this item was purchased from a non-contracted provider, without prior authorization.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to issue reimbursement for the hand-held shower head with hose (E1399) purchased on September 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on December 4, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the charges and feel that you should be charged for outpatient hospital services instead of inpatient. 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 $750 copayment for inpatient hospital care. The medical records show that you received inpatient hospital care on December 4, 2020. Therefore, you are responsible to pay the total allowed amount of $713.36, which is less than the $750 copayment. You have been asked to pay $713.36 for inpatient hospital care. Inpatient hospital care 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 inpatient hospital care provided on December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network vascular surgeon.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network vascular surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Observation care discharge day management services described by current procedural terminology (CPT) code 99217 provided on January 22, 2021.
You asked the Plan to pay for CPT code 99217. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
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 99217 is Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]). We find that CPT code 99217 is not supported in the medical record. Specifically, it is inappropriate to bill an outpatient CPT code while the enrollee is under inpatient status. Based on this information, we decided that Medicare rules for coverage of CPT code 99217 have not been met. Therefore, we decided that the Plan does not have to pay for the Observation care discharge day management services described by current procedural terminology (CPT) code 99217 provided on January 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically 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 monitor. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that in this case, you have type II diabetes and inject insulin once a day. The elements of the coverage
rule are not satisfied.
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 monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve a continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an observation stay provided on August 18, 2020.
You asked the Plan to waive the copayment for an observation stay. You say that you were told that you would not owe a copayment if you came in early and disagree with the charges. 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 $125 copayment for outpatient hospital observation. You have been asked to pay a $125 copayment for an observation stay. An observation stay falls within the outpatient hospital observation 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 observation stay provided on August 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan has to pay for ConfirmMDx testing provided on September 15, 2020.
You asked the Plan to pay for ConfirmMDx test. You say that this testing is covered by Medicare. The Plan denied your request. The Plan says that the denial of payment for this test is correct, because the enrollee had not had a prior biopsy.
The Plan follows Medicare rules. Medicare rules state that ConfirmMDx may be covered for male enrollee with previous negative biopsy who are being considered for repeat biopsy. 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 ConfirmMDx test. Our reviewer says that this testing does meet the Medicare criteria for coverage. Our physician reviewer found the enrollee received a biopsy that was negative on September 15, 2020, after which this testing was performed because of the negative biopsy result. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ConfirmMDx test have been met. Therefore, we decided that the Plan has to pay for ConfirmMDx testing provided on September 15, 2020.