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

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve routine transportation. You say that you have upcoming appointments for which you need transportation in order to attend. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation is correct, because routine transportation beyond 36 one-way trips per calendar year is not covered by the Plan.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided September 14, 2020.
You asked the Plan to pay for the orthoses. You say that you insist that this unpaid claim would be processed in an expedited manner. The Plan denied your request. The Plan says the documentation indicates the services are not necessary for the treatment of the enrollee's condition.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) received March 19, 2021.
You asked the Plan to pay for the limited oral evaluation. You say that the Plan should cover the requested service. The Plan denied your request. The Plan says the requested service is only covered under your benefit once per plan year.
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 only covered under this benefit once per plan year. The Plan last covered this service for you on March 4, 2021. When you received this service on March 19, 2021 your benefit was exhausted. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) received March 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient admission is medically
necessary. The Plan denied your request. The Plan says there is no documentation provided to support the
expectation the enrollee will require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care.
Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found that the enrollee is undergoing a planned elective total left reverse shoulder
arthroplasty. The enrollee is medically stable and has been provided medical clearance to undergo this elective
procedure. The planned procedure is listed under CPT code 23472 which is not listed on the CMS Inpatient
Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation
provided to support the expectation the enrollee will require a greater than 2 midnight stay. The record does not
show that at the time of inpatient admission the admitting physician would reasonably expect that the enrollee's
necessary hospital care will span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve the acute inpatient hospital care
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 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. 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 respiratory failure and pneumonia. Your medical conditions are stable. 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. You do require physical and occupational therapy but there is no
documented need for an intensive rehabilitation program. Medically necessary services can be provided in a
different level of care. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on March 15, 2021 and March 17, 2021.
You asked the Plan to pay for the office visit (99203) and applications of a modality (97012). You say that you were referred to the chiropractor to relieve the pain in your arm after a fall. The Plan denied your request. The Plan says these services are non-covered when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on March 15, 2021 and March 17, 2021.
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 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 complexity of the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was
admitted for cellulitis. Medical conditions 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. The patient does require physical and occupational
therapy but there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. 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 IRF admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the implant removal, by report
(D6100), bone replacement graft for ridge preservation - per site (D7953), and extraction, erupted tooth
requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if
indicated (D7210) provided March 3, 2021, and the maxillary partial denture - resin base (including,
retentive/clasping materials, rests, and teeth) (D5211) provided March 31, 2021.
You asked the Plan to provide additional payment for the implant removal, bone replacement graft, tooth
extraction and upper partial denture. You say that you don't understand why the services are not covered. The
Plan denied your request. The Plan says the implant removable and bone replacement graft are not covered services. The remaining services have been covered according to your benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the tooth extraction and upper partial denture at 50% for the Plan's covered plan allowance amount. You may pay more for services provided out-of-network. We looked at the file and Medicare rules. The Plan provided documentation showing that the tooth extraction and upper partial denture have been covered at 50% of the Plan's covered plan allowance amount. You are responsible for 50% of the covered plan allowance plus the difference between the plan allowance amount and the total amount billed by the out-of-network provider. Based on this information, we decided that the Plan does not have to provide addition payment for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided March 3, 2021, and the maxillary partial denture - resin base (including, retentive/clasping materials, rests, and teeth) (D5211) provided March 31, 2021.Though the Plan offers dental benefits in excess of Medicare coverage, the implant removal and bone replacement graft are not among those services covered. Therefore, we decided that the Plan does not have to pay for the implant removal, by report (D6100) and bone replacement graft for ridge preservation - per site (D7953) provided March 3, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the Caris MPI testing rendered on January 2, 2021.
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 that the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that next-generation sequencing is covered when
specific criteria are met.
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 these services. Our reviewer says that the
services were medically necessary. Our physician reviewer found the enrollee has a diagnosis of stage IV grade
one neuroendocrine tumor of gastrointestinal origin with liver and lymph node involvement. She had
intractable diarrhea and electrolyte disturbances. Peptide receptor radionuclide therapy (PRRT) was placed on
hold due to profuse, uncontrolled diarrhea. The testing was reasonable and necessary, as the enrollee has
advanced cancer (stages III or IV) that has not been previously tested by the same test for the same content, and
is seeking further treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for
the Caris MPI testing rendered on January 2, 2021.
Local Coverage Determination (LCD) L36807 referenced by the Plan is not valid for the state of Arizona
where the testing was performed and was not used in the MAXIMUS determination.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 17, 2020 by a non-network provider.
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 services were rendered by a non-network provider without prior authorization.
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 laboratory services provided on July 17, 2020 by a non-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compressor and accessory provided on March
14, 2020.
You asked the Plan to pay for the pneumatic compressor, segmental home model without calibrated gradient
pressure (E0651) and accessory (A9900). You say that the Plan should pay this claim. The Plan denied your
request. The Plan says the submitted documentation did not include an itemized delivery ticket, invoice, or
packing slip to indicate the specific supplies and there is no evidence of an established relationship between the
enrollee and the ordering physician.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid physician order, proof of delivery, or relevant medical records which
support medical necessity for the supplies provided in this case. There is no proof of delivery for the accessory.
There are no medical records to support criteria for the pneumatic compressor. The record shows that the Plan
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the
Plan does not have to pay for the pneumatic compressor and accessory provided on March 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stationary compressed gaseous oxygen system for the enrollee.
You asked the Plan to pre-approve a stationary compressed gaseous oxygen system. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the only indication for stationary compressed oxygen tank is for intractable cluster headaches which is not the case.
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 file shows that the enrollee has an oxygen concentrator and portable oxygen tank. An oxygen concentrator and portable oxygen tank serve the same purpose as a stationary compressed gaseous oxygen system. Therefore, we decided that the Plan does not have to pre-approve a stationary compressed gaseous oxygen system for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee brace provided on March 11, 2021.
You asked the Plan to pay for the knee brace. You say that this was medically necessary and prescribed after a telehealth consultation. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the knee brace provided on March 11, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound, abdominal, real time with image documentation (76705) provided February 10, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you are willing to pay the $30 copay for the ultrasound. The Plan denied your request. The Plan says the claim was processed with the correct copayment 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 $125 copay for Medicare covered radiological diagnostic services, not including x-rays. You have been asked to pay $71.55 for the diagnostic service. Since the allowed amount of $71.55 was less
than the copayment amount of $125, you are responsible for the lesser amount. The diagnostic service falls
within the Outpatient diagnostic tests and therapeutic services and supplies 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 ultrasound, abdominal, real time with image documentation
(76705) provided February 10, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI of the lumbar spine. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested MRI of the lumbar spine is to assess the osseous components of the lumbar spine for possible multiple myeloma. The most usual request for this test is not pertinent in this case; back pain with neurological features. The requirement for a 6-week trial of conservative management prior to authorizing MRI of the lumbar spine does not apply in this case. Exam should be approved. 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 MRI of the lumbar spine have been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
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.