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

We decided that the Plan does not have to waive the coinsurance for the MRI provided on October 5, 2019.
You asked the Plan to waive the coinsurance for the MRI. You say that you had had other sorts of diagnostic radiology services and never been billed for it. You say that you were advised there was no copayment. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance up to a maximum of $75 per day for Medicare-covered diagnostic radiology services. You have been asked to pay $55.92, which is 20% of the allowed amount for the MRI. The allowed amount is $279.60 (20% x $279.60 = $55.92). The MRI 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 coinsurance for the MRI provided on October 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a gym membership provided from January 17, 2017 to December 17, 2017.
You asked the Plan to reimburse you for the gym membership. The Plan denied your request. The Plan says the claim was filed after the time limit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because the claim was filed beyond the time limit. Therefore, we decided that the Plan does not have to reimburse you for a gym membership provided from January 17, 2017 to December 17, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvepower wheelchair accessories (expandable controller, harness, electrical connection, and power tilt and recline system for the enrollee.You asked the Planto pre-approvethe accessories. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no medical need to control the power options through the joystick.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 accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires a proportional input device, an attendant control, other electronic devices such as augmentative speech device, a separate display, a non-proportionalinput device suchas sip and puff, or the need to control 3 or more power seating actuators through the drive control. The enrollee's strength and functional ability to perform grooming and eating indicate that she has sufficient function to control the power options with their separate switches already included with the approval of these power options.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 accessories have not been met.Therefore, we decided that the Plandoes not haveto pre-approvepower wheelchair accessories (expandable controller, harness, electrical connection, and power tilt and recline system for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out-of-network services. You say that you have been seeing this provider for over 30 years. The Plan denied your request. The Plan says you have in-network providers available in your area.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these out-of-network services. Therefore, we decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve urology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out-of-network services. You say that you were referred to the doctor for your condition. The Plan denied your request. The Plan says the service requested is 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these out-of-network services. Therefore, we decided that the Plan does not have to pre-approve urology services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forneurology services provided to the enrollee on November 6, 2019.You asked the Plan to pay fortheservices. You say that this should be paid for.The Plan denied your request. The Plan says these CPT codes have a Physician Fee Schedule PCTC indicator as "1."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 the denied codes is:CPT 95937:Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method.CPT 95870:Needle electromyography; limited study of muscles in one extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters CPT 95937:Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs.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 coded correctly. Our coding reviewer found CPT codes 95937, 95870, and 95938 all have a physician PCTC indicator of "1" and were billed in Place of Service 21 (Inpatient Hospital) The Medicare Claims Processing Manual states that "A/B MACs (B) may not pay for the technical component (TC) of radiology services furnished to hospital patients. Payment for physicians' radiological services to the hospital, e.g., administrative or supervisory services, and for provider services needed to produce the radiology service, is made by the AB MAC (A) to the hospital as a provider service. "The professional interpretation of a diagnostic test would need to be submitted with a 26 modifier in order to be considered for reimbursement. Medicare rules for payment consideration has not been met with. Medicare rules state, "For Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation AND confirm that coverage criteria have been met. Physicians must report services correctly."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 forneurology services provided to the enrollee on November 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says that your condition does not currently meet requirements for admission in a skilled nursing facility.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.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-approveskilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehypoglossal nerve stimulation.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that procedure code 0466T is considered not reasonable and necessary.The services at issue are hypoglossal nerve stimulation described by procedure code 0466T. These services are denied by Medicare as not reasonable or medically necessary.Therefore, we decided that the Plan does not have to pre-approvehypoglossal nerve stimulation. The Plan references Local Coverage Determination (LCD) L35094 in their determination. While this LCD is for the correct jurisdiction, the effective date is not valid so this was not used in the MAXIMUS determination.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea coronary computed tomography (CT) scan with quantitative calcium screening.You asked the Plan topre-approvethese services. You say that you need to know what is wrong with your heart.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that a coronaryCT 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have a history of hyperlipidemia (high concentration of fat/lipids in the blood) and documented vascular disease. In this circumstance, a coronary calcium screening would not provide information necessary for treatment. Aggressive risk-factor modification is indicated regardless of the CT scan results. The CT scan is therefore not reasonable or medically necessary at this time, as it would be performedfor screening purposes.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 not been met.Therefore, we decided that the Plan does not have topre-approvea coronary computed tomography (CT) scan with quantitative calcium screening.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto for the enrollee.
You asked the Plan to pre-approve Entresto. You say that the enrollee's symptoms improved with a beta-blocker and Entresto. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Entresto for the enrollee.
Benefits for Entresto may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from August 29, 2019 to August 30, 2019.
You asked the Plan to pay for inpatient care. You say that inpatient admission was medically necessary and you provided complete medical records for review. The Plan denied your request. The Plan says the enrollee's emergency medical condition stabilized by 6:25 am on August 29, 2019. Subsequent care was post stabilization care. It was not approved in compliance with the health plan's authorization procedures. The Plan paid for all emergent care up to the point of stability.
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 inpatient care. Our reviewer says that the service was not medically necessary. Our physician reviewer found that the enrollee arrived at the emergency department (ED) with a chief complaint of cough and congestion for 30 minutes with shortness of breath and mid-chest tightness. The enrollee was alert and oriented in moderate distress. She was assessed to have positive rhonchi and wheezing and was placed on oxygen. Electrocardiogram (EKG) showed sinus tachycardia and chest x-ray revealed chronic obstructive pulmonary disease (COPD). By 6:25 am the enrollee's emergent medical condition was assessed and stabilized because her EKG revealed no acute changes. The enrollee was treated with a hand-held neutralizer and she was admitted in stable condition.
The review indicates that by 6:25 a.m. on August 29, 2019, the enrollee was stable for ambulance transport with oxygen and monitoring to a Plan facility because the enrollee's emergent medical condition was assessed and stabilized. There was no documentation provided necessitating post-stabilization care services after 6:25 a.m. on August 29, 2019. Post-stabilization care services from August 29, 2019 to August 30, 2019 were not medically necessary and reasonable. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care provided from August 29, 2019 to August 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycontin for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee is in pain. The Plan denied your request. The Plan says that this medication is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycontin for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.
You asked the Plan to pre-approve the proton beam therapy. You say that the records provided support the medical necessity of proton beam therapy. The Plan denied your request. The Plan says the type of treatment being requested is not known to be more effective than other types of radiation therapy for the enrollee's cancer. The Plan says that intensity-modulated radiation therapy would be approved if requested.
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 proton beam therapy. Our reviewer says that proton beam therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has low risk prostate cancer. Our physician reviewer found that there are ongoing prospective randomized trials are ongoing comparing proton beam therapy to intensity modulated radiation therapy for treatment of prostate cancer. At this time, proton beam therapy is not considered medically reasonable and necessary for the treatment of prostate cancer. The options for treatment of this cancer type include brachytherapy and external beam radiation therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on March 27,
2019.
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 testing is not covered.
The Plan must follow Medicare rules. The rules say that all circulating tumor cells (CTC) assays are noncovered.
We looked at the file and Medicare rules. The services at issue are a CTC assay. This testing is non-covered by
Medicare. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on March 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on July 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you had to get a new doctor because your old one was no longer in-network. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 an office visit provided on July 22, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from August 7, 2019 through August 10, 2019.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you had a reaction to the medication and you had to return to the hospital less than 24 hours later. You state this should be considered one admission. The Plan denied your request. The Plan says your previous inpatient stay rendered from August 3, 2019 through August 6, 2019 is considered a separate admission because during the second admission, you were being treated for an allergic reaction that you had to the antibiotics (after you were discharged on August 6, 2019). The Plan states since you did not develop an allergic reaction to the antibiotics during the initial (first) stay, the admissions are not related and are considered separate inpatient stays.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file shows that you were admitted on August 7, 2019 and discharged on August 10, 2019. You were asked to pay a $350 copayment per day from August 7, 2019 through August 9, 2019, days 1-3 of your inpatient hospital care. You were discharged on August 10, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $350 copayment per day required for days 1-5. 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 inpatient hospital care from August 7, 2019 through August 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says a valid authorization was not obtained before the services were provided to the enrollee. The Plan says the services were not urgent or emergent. The Plan also says it is the responsibility of the provider to verify the plan requirements prior to rendering services to the enrollee.
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 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 September 23, 2019 by an out of network (OON) provider.