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

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do 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 SNF care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the filling (D2392) and the lower partial denture with a flexible base (D5226).

You asked the Plan to pay the full amount for the dental services. You say that you have been diagnosed with gingival overgrowth as a side effect of Dilantin. You say that your dentist believes you would benefit from a lower partial denture and a filling as you cannot bite or chew food properly. The Plan denied your request. The Plan says there is a $85 copayment for fillings. The Plan also says that partial lower denture is 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, there is an $85 copayment for fillings. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Additionally, the partial lower denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the full amount for the filling (D2392) and the lower partial denture with a flexible base (D5226).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care.

You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.

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 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 subsequent nursing facility care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electroencephalogram (EEG) monitoring services provided by an out of network (OON) provider.

You asked the Plan to pay for the EEG monitoring services. You say that there were no in-network physicians available to cover the overnight shift in the ICU. This enrollee was in the ICU and under critical care treatment for this date of service. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for electroencephalogram (EEG) monitoring services provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, each additional intraoral periapical x-ray, resin-based composite, maxillary partial denture, and add tooth to existing partial denture.

You asked the Plan to pay for the intraoral periapical x-rays, resin-based composite, maxillary partial denture, and add tooth to existing partial denture. You say that you do not agree with these services not being paid for by the Plan. The Plan denied your request. The Plan says your benefit period maximum for the calendar year was reached.

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 Plan offers an annual $1,200 benefit maximum per calendar year. The record shows that you met the annual maximum benefit and your annual maximum benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray, each additional intraoral periapical x-ray, resin-based composite, maxillary partial denture, and add tooth to existing partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that these services are medically necessary. The Plan
denied your request. The Plan says that you do not meet criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least
three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing
results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met.
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor
(CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance the wound dressings.

You asked the Plan to waive the coinsurance these services. You say that you do not feel liable. The Plan denied your request. The Plan says the coinsurance was 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 20% of the plan-allowed amount for in-network Medicare-covered durable medical equipment.

Review of the file shows that you received wound dressings. You have been asked to pay 20% of the plan-allowed amount for these services. These services fall within the in-network Medicare-covered durable medical equipment 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 coinsurance the wound dressings.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0427 and A0425).

You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because the member was treated according to the 911 call. The Plan denied your request. The Plan says this service was not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 member's presenting symptoms did not meet layperson criteria for emergency care. Our physician reviewer found other means of transport were not contraindicated and the member did not require special equipment or expertise.

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 ambulance services (A0427 and A0425).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (PCD) (E0651, E0667).

You asked the Plan to pay for the services. You say that the documentation supports this request. The Plan denied your request. The Plan says there is no documentation of one or more venous ulcer(s) which have failed a six-month trial of conservative therapy.

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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal evidence on a physical exam from the treating medical provider of persistent chronic and severe lymphedema, as defined by the guidelines or evidence of a failure of a four week trial of conservative therapy.

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 a pneumatic compression device (PCD) (E0651, E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a referring provider. The Plan says that the member's primary care physician did not refer these services.

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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that Indian Health Service (IHS) providers are paid
by Medicare for covered outpatient services based upon an all-inclusive outpatient per visit rate (AIR). The
AIR is established by Medicare and IHS based upon a review of yearly cost reports prepared by IHS's
contractor. All charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus
vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue
code 0510 (clinic visit) on TOB 13X (hospital outpatient).

We looked at the file and Medicare rules. The services in question were not billed according to Medicare
guidelines. 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.

We note that it appears a corrected claim was submitted directly to Maximus during the review of this case. We
cannot act on or process claim corrections. Corrected claim information may be submitted directly to the Plan
for further review. We are only permitted to make a decision based on the claim information reviewed by the
Plan for payment. Please submit any corrections or additional claim information directly to the Plan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided by an OON provider.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that when you contacted the Plan about this providers status you were advised that this provider was in-network. The Plan denied your request. The Plan says this service was rendered by an OON provider. The Plan also says that services are only covered by your plan for in-network dentists.

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 covered when they are received OON. The record shows that you did not contact the Plan prior to receiving this service. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services.

You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says
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 Plan says that the Plan has also determined that these services are not
urgent or emergent, nor were they approved in advance.

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
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 diagnostic radiology services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Myocardial Perfusion Imaging (78452).

You asked the Plan to waive the copayment for the Myocardial Perfusion Imaging. You say that the copayment
should be waived. The Plan denied your request. The Plan says the correct copayment 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 a $50
copayment for advanced imaging services.

You have been asked to pay a $50 copayment for the Myocardial Perfusion Imaging. The Myocardial Perfusion
Imaging falls within the advanced imaging 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 Myocardial Perfusion Imaging (78452).
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 the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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. Our
physician reviewer found based on the documentation provided, the health plan's denial should be upheld. You
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a
lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the biopsy (76942, 55700, 76872) to be provided by an 
out of network (OON) provider. 
 
You asked the Plan to pre-approve an OON biopsy. You say that only out-of-network doctors can perform a 
transperineal biopsy. The Plan denied your request. The Plan says you can receive the necessary services 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 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 provider at issue in this case is not a network provider with the Plan. 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 an OON biopsy. Our reviewer says that the criteria for OON services have 
not been met. Our physician reviewer found the prostate biopsy can be safely performed by an available in-
network provider. The overall complication rate is similar between transperineal and transrectal approaches. 
The infection rate is higher with the transrectal approach, but other complications associated with the 
transperineal approach make up the difference. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an OON biopsy have not been met.  
 
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 an OON biopsy. Therefore, we decided that the Plan 
does not have to pre-approve the biopsy (76942, 55700, 76872) to be provided by an out of network (OON) 
provider.
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 would not benefit from an intensive rehabilitation program, do not 
have complex medical management needs and do not require supervision by rehabilitation physician. 
 
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 a subarachnoid hemorrhage 
after a fall and for a COVID-19 infection. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 9, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an outpatient rehabilitation 
setting and should have been billed with POS code 57. Therefore, we decided that the Plan does not have to 
pay for the drug testing rendered on April 9, 2020.