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

We decided that the Plan does not have to pay for an inpatient admission provided from September 18, 2020, through September 19, 2020.

You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says the non-participating provider did not request 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 inpatient admission. 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 an inpatient admission provided from September 18, 2020, through September 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.

You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 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 a Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex spacer is experimental. More research is needed to show safety and efficacy of the device. Open laminectomy remains the gold standard for lumbar decompression. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on December
13, 2019, by an OON provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that there is currently no innetwork
doctor who can treat the enrollees in the facility. The Plan denied your request. The Plan says the
service was rendered by a non-network provider who does not work with the enrollee's health plan. The Plan
also says that the enrollee was referred by his non-participating outpatient nursing facility.

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 the subsequent nursing facility care provided on
December 13, 2019, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from August 16, 2020, to
August 18, 2020.

You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was
stable for transfer.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.

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 care. Our reviewer says that the
requested inpatient care was not medically reasonable and necessary. Our physician reviewer found that the
enrollee is an 83-year-old male who arrived at the emergency department by ambulance after a ground level
fall. He complained of shoulder pain and oxygen sat was 65% on room air. He was intubated and admitted with
acute on chronic respiratory failure. He was extubated by August 14, 2020. Upon review of the provided
records, there was no annotation or report of the enrollee being unstable for transfer. Based on the
documentation, the enrollee appeared to be stable for transfer on August 16, 2020, at 12:00 am.

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 inpatient care have not been met. Therefore, we decided that the Plan does
not have to pay for the inpatient hospital care provided from August 16, 2020, to August 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile imaging services provided on July 27, 2020.

You asked the Plan to pay for the imaging services. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. In this case place of service (POS) code 31 would indicate that the enrollee was in a Part A covered stay. This means that the setup and transport would not be billable to the plan by the provider, but by the SNF. Therefore, reporting POS code 31 is not appropriate. The correct POS code would be 32, which indicates a non-covered SNF stay. Based on this information, we decided that Medicare rules for coverage of the imaging services have not been met. Therefore, we decided that the Plan does not have to pay for the mobile imaging services provided on July 27, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from November 9, 2020, to November 11, 2020 billed with code S9330.

You asked the Plan to pay for the HIT services. You say that this should be covered. The Plan denied your request. The Plan says the codes billed are not valid.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

CPT code S9330 has a status indicator of "I" in the Physician Fee Schedule. This means it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the HIT services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from November 9, 2020, to November 11, 2020 billed with code S9330.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing service (D4341) provided on December 3, 2020.

You asked the Plan to pay for periodontal scaling and root planing. You say that you should not have to pay out-of-pocket for dental, and you have a secondary insurance with another company. The Plan denied your request. The Plan says this benefit is not covered by the mandatory supplemental benefit. You requested to be disenrolled from the optional supplemental portion effective December 1, 2020, which did offer coverage of this 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. 

The Plan provided documentation of your request and subsequent disenrollment from the Plan's additional optional supplemental dental benefit prior to the date of service in question. The mandatory benefit, which is automatically included with your plan, only covers certain routine preventative services. If you have a secondary insurance company that offers coverage of this service, the request needs to be submitted to them separately, as your primary Plan does not have the jurisdiction to review or provide payment for services the secondary plan may cover.

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 the periodontal scaling and root planing service (D4341) provided on December 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 5, 2019.

You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment is waived if you are admitted. You say that you cannot afford this bill. 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 $200 copayment for Medicare-covered ambulance benefits for each one-way trip. 

You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 ambulance transport provided on December 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on September 2, 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 to the enrollee by an out-of-network provider on September 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 11, 2020.

You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on June 11, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 11, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care services (T1019).

You asked the Plan to pre-approve the personal care services. The Plan denied your request. The Plan says neither Medicare nor your health plan covers this care.

The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the personal care services have not been met. Therefore, we decided that the Plan does not have to pre-approve personal care services (T1019).
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance transportation to a skilled nursing facility on August 19, 2020.

You asked the Plan to pay for the ambulance transportation. The Plan denied your request. The Plan says that this is not a covered benefit.

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 records show that the service at issue is transportation from a doctor's office to a skilled nursing facility. Medicare covers ambulance transportation "from any point of origin to the nearest hospital or skilled nursing facility (SNF) capable of furnishing appropriate care for a patient's illness or injury". The Plan has not provided documentation to support its denial. Therefore, we decided that the Plan has to pay for the ambulance transportation to a skilled nursing facility on August 19, 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating hospital.

You asked the Plan to waive the copayment for an ultrasound. You say that you were told that this would be covered 100%. 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 $25 copayment for outpatient diagnostic tests/in-network/basic radiological services/outpatient hospital.

You have been asked to pay a $25 copayment for an ultrasound. The correct copayment has been applied to the services that were provided. An ultrasound falls within the outpatient diagnostic tests/in-network/basic radiological services/outpatient hospital 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 ultrasound provided by a participating hospital.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on December 31, 2020.

You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. 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 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 nurse practitioner services provided on December 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel (81407, 81479, 81286 and 81408) provided on September 9, 2020.

You asked the Plan to pay for the cardiovascular risk assessment.. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing/panels.

The Plan must follow Medicare rules. Medicare rules say that cardiovascular disease screening must be submitted with specific CPT codes. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cardiovascular risk assessment. have not been met. Specifically, this testing is not a Medicare covered benefit. The CPT codes for cardiovascular disease screening are not present on the billed claim. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel (81407, 81479, 81286 and 81408) provided on September 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were never told that you were formally admitted. You say that you have quality of care concerns as well. 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 $450 copayment per day for days 1-4 for inpatient hospital care.

You have been asked to pay a $450 copayment per day for days 1-2 for an inpatient hospital stay. The total amount you are being asked to pay is $900 ($450 x 2 days = $900). 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.

Your quality-of-care concerns have been handled separately by the health plan. Medicare does not permit Maximus to make a decision on this type of complaint.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the trigger point injections and acupuncture provided on June 25, 2020 and June 29, 2020.

You asked the Plan to reimburse you for the trigger point injections and acupuncture. You say that the Plan should pay the claims. The Plan denied your request. The Plan says the diagnosis codes do not comply, and the provider is not contracted.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT and diagnosis codes. 

We find that code 20553 is not supported in the medical record. Specifically, the diagnosis code does not support medical necessity for the trigger point injections according to the Local Coverage Article. The provider in this case is not a network provider with the Plan and the Plan did not pre-authorize the acupuncture service. Based on this information, we decided that Medicare rules for coverage of the trigger point injections and acupuncture have not been met. Therefore, we decided that the Plan does not have to reimburse you for the trigger point injections and acupuncture provided on June 25, 2020 and June 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Group 3 power wheelchair and accessories (CPT code K0856).

You asked the Plan to pre-approve the DME. You say that you will need this power wheelchair in order to get around your home and public settings. The Plan denied your request. The Plan says DME is not covered for use primarily outside of the home.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 DME. Our physician reviewer found the requested Group 3 power wheelchair K0856 with multiple power options is not medically necessary per the LCD PMD (L33789). You do not have a mobility limitation due to a neurological condition, Myopathy, or congenital skeletal deformity; therefore, you do not meet the medically necessary criteria for this Group 3 power wheelchair and this request is not medically 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve Group 3 power wheelchair and accessories (CPT code K0856).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does not require skilled nursing or rehab services on a daily basis in a SNF.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that from a nursing perspective, the enrollee received oral and inhaled medications, and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a contact guard to minimal assist level for functional mobility. Although there are identifiable skilled therapy service needs, the enrollee 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.