Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary-level referral to an oncologist.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's condition did not meet the medical necessity criteria for a tertiary-level provider.
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 referral. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are able to be managed by an in-network provider. Colon cancer is able to be treated by a network provider. 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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a tertiary-level referral to an oncologist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 4, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 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 by an out-of-network provider on March 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe mammogram provided on October 19, 2020.You asked the Plan to pay forthe mammogram. The Plan denied your request. The Plan says the benefit limit has been exceeded.The Plan must follow Medicare rules. Medicare rules say that payment may be made for only one screening mammography performed on a woman over age 34, but under age 40. We looked at the file and Medicare rules. The records show that the requested mammogram was the second provided to the enrollee between the ages of 35 and 40. The first mammogram, provided on September 18, 2019, was paid by the Plan. The second mammogram exceeds the Medicare limit. Based on this information, we decided that Medicare rules for coverage of the mammogram have not been met.Therefore, we decided that the Plan does not have to pay forthe mammogram provided on October 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (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 Skilled Nursing Facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant provided on December 8, 2020.
You asked the Plan to pay for the endosteal implant. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service is 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. 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 surgical placement of implant body: endosteal implant provided on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction you received on January 13, 2021.
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.
The services you asked the Plan to pay for are considered routine vision services or eyewear. Neither Medicare or the Plan covers eye refractions. Therefore, we decided that the Plan does not have to pay for the eye refraction you received on January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses provided on February 10, 2021.
You asked the Plan to pay for the knee orthoses (L1833). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no information that the enrollee's provider stated a brace would be ordered or the quantity of items ordered.
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 or relevant medical records which support medical necessity for the supplies provided in this case. The physician order was not written by the enrollee's physician and there is no mention in the enrollee's medical record, from January 2021, of prescribing knee orthoses. 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 knee orthoses provided on February 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 provided on January 9, 2021, January 10, 2021, and January 12, 2021.
You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the critical care services provided on January 9, 2021 was previously paid. The critical care services provided on January 10, 2021 and January 12, 2021 are considered as part of the global surgical package of the major procedure 44005 (Enterolysis (freeing of intestinal adhesion) (separate procedure)) billed on the date of service January 5, 2021. Both providers are within the same group and have the same primary specialty-Internal Medicine. This means that these services are not separately payable. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided on January 9, 2021, January 10, 2021, and January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services received January 21, 2020 through February 17, 2020.You asked the Plan to pay forthe dental services. You say that you should be reimbursed $500.The Plan denied your request. The Plan says you exhausted your $500 benefit allowance in the requested claims.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 payment is in excess of that which is covered under this benefit. You exhausted your $500 benefit allowance in the requested claim. Therefore, we decided that the Plan does not have to pay forthe dental services received January 21, 2020 through February 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D4273, D1999) received November 23,
2020, from the out-of-network provider.
You asked the Plan to pay for the dental services (D4273, D1999). You say that the provider did not inform
you that they were not in-network. The Plan denied your request. The Plan says you must use a network dental
provider in order to obtain your supplemental dental 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.
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. You did not obtain these services from a network provider. Therefore,
we decided that the Plan does not have to pay for the dental services (D4273, D1999) received November 23,
2020, from the out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for full body bone imaging (78306) and chemotherapy services (J0897, J9217) provided on October 29, 2020.
You asked the Plan to waive the cost-sharing for full body bone imaging and chemotherapy services. You say that Medicare and the Plan should pay more for the services. The Plan denied your request. The Plan says the cost-share you are being charged is correct.
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 20% coinsurance for Medicare Part B prescription drug. Your contract with the Plan also clearly says that you must pay a $100 copayment for outpatient diagnostic tests and therapeutic services and supplies rendered at an outpatient hospital.
You have been asked to pay a 20% coinsurance and a $100 copayment for chemotherapy services. The allowed amount of the claim is $3,360.71, resulting in a coinsurance of $616.04 and a copayment of $100 ($616.04 + $100 = $716.04). The EOC confirms that this is the correct cost-share for this service. Chemotherapy services fall within the Medicare Part B prescription drug and full body bone imaging 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 cost-sharing for full body bone imaging (78306) and chemotherapy services (J0897, J9217) provided on October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the requirement is that the initial treatment resulted in a better than 50% improvement in
symptoms based on the initial rating scale score.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the documentation presented does not show a 50% percent improvement of the PHQ 9 score
from the previous episode of TMS. Utilizing this information, you do not meet the requirements.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve transcranial magnetic stimulation (TMS).
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 the enrollee meets IRF admission criteria. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the enrollee 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department services (CPT 99284) provided to the enrollee on January 21, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says an appropriate diagnosis code was not listed as the primary, or principal diagnosis.

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 99284 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity." 

We asked our coding 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 services at issue in this case were not supported by the medical records. Our coding reviewer found the billing documentation submitted shows the claim was submitted with T50.905A as primary diagnosis, which has a "code first" note for adverse effects, the nature of adverse effects. Because the claim was not submitted with an appropriate primary diagnosis code, there it cannot be considered for reimbursement. 

We looked at this coder'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 emergency department services (CPT 99284) provided to the enrollee on January 21, 2021.
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 IRF is medically necessary for you. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 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 waive the copayment for an emergency ambulance transport (A0427) provided on January 20, 2021.
You asked the Plan to waive the copayment for an emergency ambulance transport. You say that you did not want to go by ambulance. The Plan denied your request. The Plan says the copayment 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 a $50 copayment for ambulance services. You have been asked to pay a $50 copayment for an emergency ambulance transport. The service at issue 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 an emergency ambulance transport (A0427) provided on January 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pneumatic compression device (E0651) and garments (E0667x2).

You asked the Plan to pre-approve the pneumatic compression device and garments. You say that you ask for reversal of the denial with the enclosed clinical documentation to support the enrollee has medically necessary reasons for the prescribed pneumatic compression device. The Plan denied your request. The Plan says the records do not support that the enrollee meets the criteria.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 

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 pneumatic compression device and garments. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found upon review of the records, there was insufficient evidence provided that the enrollee suffered from chronic/severe lymphedema with marked hyperkeratosis with hyperpigmentation and hyperplasia or papillomatosis cutis lymphostatica, or deformity of elephantiasis or skin breakdown from persistant lymphorrhea. Also, there was no documentation of having failed standard compression bandage or device or limb elevation and exercise. Therefore, based on the provided records, this patient does not meet the Medicare criteria for a pneumatic compression device and garments as requested. 

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 pneumatic compression device and garments have not been met. Therefore, we decided that the Plan does not have to pre-approve pneumatic compression device (E0651) and garments (E0667x2).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the $300 copayment charged for outpatient hospital services provided on September 25, 2020.
You asked the Plan to waive this copayment. You say that this was a colonoscopy screening and should be no charge. The Plan denied your request. The Plan says the $300 copayment is not for the colonoscopy itself but for the facility it was performed in. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract language.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $300 copayment for colorectal services provided in an ambulatory center or outpatient hospital facility. You have been asked to pay the correct amount based on your contract with the Plan, the facility the service was provided in and the claim submitted by your provider. 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 $300 copayment charged for outpatient hospital services provided on September 25, 2020.