Persius/hicric huggingface dataset:
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 you do not feel that a skilled nursing home will be 
beneficial for you. The Plan denied your request. The Plan says the IRF services you are requesting do not meet 
the requirements for approval. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
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. Our physician 
reviewer also found that 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay foranesthesia (01936) provided on August 3, 2020.You asked the Plan to pay foranesthesia. You say that this service is not bundled because the procedures at issue were provided by different providers.The Plan denied your request. The Plan says that code 01936 is a column II procedure to the column I procedure, 72275, and is not separately reimbursable even when a modifier is appended.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 Plan states that code 01936 is a column II procedure to 72275. While this is the case, the Plan has not included any documentation showing that code 72275 was billed for this date of service. Without this information, the application of NCCI edits cannot be verified.Therefore, we decided that the Plan has to pay foranesthesia (01936) provided on August 3, 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: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pay forcosmetic surgery provided on April 28, 2020.You asked the Plan to pay forcosmetic surgery. You say that the Plan should pay for this surgery.The Plan denied your request. The Plan says this type of surgery is not covered by Medicare. Maximus overturned the Plans denial administratively due to information that was lacking in the case file. The Plan requested a reopen and provided additional information regarding this procedure. The Plan says that according to the operative notes, "Tumescent Liposuction was requested for excessive fat of the lower abdomen".  The Post-operative notes the services performed were "Liposuction Tumescent".  The medical records confirm the service performed was with small incision sites and no sutures used to close the wounds.The records do not show you had a panniculectomy. The codes billed were not for a panniculectomy.  The Plan states the Medicare rules are clear that liposuction is not covered. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures are not covered. The LCD specifically states that liposuction is not covered. The Plan contract states only two types of cosmetic surgery that are covered, neither of which were provided. The Plan did not authorize this surgery. Based on this information, we decided that Medicare rules for coverage of this surgery were not met. Therefore, we decided that the Plan does not have to pay forcosmetic surgery provided on April 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe radiology services provided on November 4, 2020.You asked the Plan to waive the copay forthe services provided. The Plan denied your request. The Plansays the copay is applicable to the global and technical components of diagnostic radiology services only.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 copay for each diagnostic radiology service. You have been asked to pay a $20 copay for the services provided. The services fallwithin the outpatient diagnostic tests 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 copay forthe radiology services provided on November 4, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe ultrasounds rendered on June 1, 2020.You asked the Plan to waive the copayments forthese services. You say that you disagree with the charges.The Plan denied your request. The Plan says the copayments were 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 $110 copayment for each Medicare-covered radiological diagnostic service, not including x-rays,performed in a physician's office or at a freestanding facility. Review of the file shows that you received an ultrasound of the right breast and an ultrasound of the left breast on June 1, 2020. Per the contract with the Plan, there is a $110 copaymentfor each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $103.84. Given that the allowed amount was less than the $110 copayment, you have been asked to pay $103.84 per ultrasound for these services, for a total of $207.68.Therefore, we decided that the Plan does not have to waive the copayments forthe ultrasounds rendered on June 1, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from August 3, 2020, to August 24, 2020.You asked the Plan to pay forhome health services. You say that this should be processed per visit rather than episodically.The Plan denied your request. The Plan says this was not billed with a correct type of bill code.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this was billed with the type of bill code 0323, which is not valid for home health services.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from August 3, 2020, to August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, five additional intraoral 
periapical x-rays, bitewing x-rays, prophylaxis, and occlusal guard provided on June 11, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the periodic oral evaluation, additional intraoral periapical x-rays, bitewing x-
rays, prophylaxis, and occlusal guard. You say that you were not advised prior to this appointment that this 
provider did not accept your insurance. The Plan denied your request. The Plan says these services were 
rendered by an OON provider. The Plan also says that services performed by an OON provider are not covered 
because your healthcare plan does not have OON 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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation, five additional intraoral periapical x-rays, bitewing x-rays, prophylaxis, and occlusal guard 
provided on June 11, 2020 by an OON provider.  
 
Your complaint about not being advised prior to your appointment that the provider is OON is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe unspecified preventive service (D1999) provided on September 2, 2020.You asked the Plan to pay forthe unspecified preventive service. You say that you made an appointmentwith one provider and ended up seeing a different provider on the date of service. You say that the provider you made the appointment with is no longer there. You say that you were never advised that the new provider was out of network. You also say that you would not have seen him had you known he was out of network.The Plan denied your request. The Plan says the unspecified preventive service 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe unspecified preventive service (D1999) provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered.

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 procedure code 99291 is not supported.

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, there is no documentation of 30-74 minutes of critical care services spent on the enrollee. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe critical care services rendered.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on September 9, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1,2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for these services was not filed until October 24, 2020. A valid Waiver of Liability (WOL) was not received until December 14, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on September 9, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe vascular surgery (37799, 36581 and 77001) provided on July 2, 2020.You asked the Plan to pay forthe vascular surgery. You say that you would like reconsideration because this service was performed in the correct place of service.The Plan denied your request. The Plan says the member was registered inpatient on the billed date of service.The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the vascular surgery have not been met. Specifically, the record indicates that the member was registered inpatient on the billed date of service. It is not appropriate to bill an outpatient place of service code when the member is registered inpatient.Therefore, we decided that the Plan does not have to pay forthe vascular surgery (37799, 36581 and 77001) provided on July 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (P9604, 80053, 80061, 85025, 82607, 
84443, 87493, 80048) provided from August 12, 2020, to September 9, 2020, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for OON laboratory services. You say that the patient is in a nursing home and 
cannot choose providers. The Plan denied your request. The Plan says these services were not authorized. 
 
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 (P9604, 80053, 80061, 
85025, 82607, 84443, 87493, 80048) provided from August 12, 2020, to September 9, 2020, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the surgical procedure provided on January 14, 2020.
You asked the Plan to waive the copayment for the surgical procedure. You say that you do not know why you are being charged this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $250 copayment for Outpatient Surgery. You have been asked to pay a $250 copayment for the surgical procedure. The surgical procedure falls within the Outpatient Surgery 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 surgical procedure provided on January 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea low dose CT scan of the lungs for the enrollee.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The Plansaysthe clinical information provided does not describethe correct imaging timeframe.The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the most appropriate test is a dedicated diagnostic non-contrast chest CT, which has already been approved, rather than a LDCT. The purpose of this test is for followup of suspicious nodules, rather than cancer screening, and a normal dosing protocol is considered standard practice in order to provide the best sizing of the nodules.
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 scan have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea low dose CT scan of the lungs for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional accessories for a power wheelchair (E2313, E2311) for the enrollee.You asked the Plan to pre-approvethe additional accessories. You say that this is medically necessary.The Plan denied your request. The Plan says the wheelchair is approved except for E2311 and E2313.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 additional accessories. 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 that the enrollee requires other types of proportional input devices(e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. 
The enrollee's strength and functional ability of independent feeding are sufficient for the enrollee to control any power options through their own switches.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 additional accessories have not been met.Therefore, we decided that the Plan does not have to pre-approveadditional accessories for a power wheelchair (E2313, E2311) for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe crown provided on August 6, 2020.You asked the Plan to pay forthe crown. You say that you were not aware that the provider had opted out of Medicare until after the initial claim was denied.The Plan denied your request. The Plan says the treating provider has opted out of Medicare effective March 31, 2016 to March 31, 2022. The Plan also says that charges incurred by Medicare Opt Out providers will not be reimbursedby the Plan.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. The Plan confirmed with the provider's office that you were verbally informed that this provider does not accept Medicare.Therefore, we decided that the Plan does not have to pay forthe crown provided on August 6, 2020
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided 
on July 24, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you were told 
when you signed up with the Plan that you would only owe a $90 copayment for the injections. The Plan 
denied your request. The Plan says the claims were processed correctly and you are being charged the correct 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received a Medicare Part B drug on July 24, 2020. The allowed amount is $4,029.20 and 20% of that is 
$805.84.  
 
You have been asked to pay the total coinsurance amount of $805.84 for a Medicare Part B drug injection. A 
Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 for a Medicare Part B drug injection provided on July 24, 2020.  
 
We note your complaint that you were misquoted when you signed up with the Plan. Your complaint is a 
grievance that must be answered by the health plan. Medicare does not permit us to make a decision about 
these types of complaints.