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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that it is felt that LTACH care is necessary.The Plan denied your request. The Plan says this level of care is not clinically superior to the current facility.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient who was admitted to the current acute care hospital with community acquired pneumonia and associated acute respiratory failure requiring mechanical ventilation support and antibiotics. She has since been able to wean to high flow oxygen but is more recently with respiratory instability due to ongoing pneumonia.

The patient appears to be improved somewhat but still requires additional short-term additional acute care services to further wean from oxygen and complete treatment of her pneumonia, that can be safely completed at the current facility. The patient does not require services at the LTACH that are not already available at the current facility.Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered when the patient is more stable and when treatment has completed.

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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve longterm acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (78451).
You asked the Plan to pre-approve myocardial perfusion imaging, tomographic. You say that the requested
services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for
myocardial perfusion imaging have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve myocardial perfusion imaging,
tomographic. Our reviewer says that the requested services are not considered medically reasonable and
necessary in this case. Our physician reviewer found that the record indicates that the enrollee has dyspnea on
exertion. The record does not indicate why the enrollee cannot undergo an exercise stress test. The
electrocardiogram is not uninterpretable. The record does not indicate that the enrollee has a condition
enumerated in the coverage criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of myocardial perfusion imaging, tomographic have not been met. Therefore, we
decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (78451).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe vacuum erection device.You asked the Plan to pre-approvethe device. You say that you suffer from erectile dysfunction as a consequence ofprostate cancer. You state this would improve your life and is an alternative to having to undergo surgery where you indicate you are at risk for infection.The Plan denied your request. The Plan says this is not covered by Medicare.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. The rules say that vacuum erection devices (L7900) and related accessories (L7902) are statutorily non-covered.Therefore, we decided that the Plan does not have to pre-approvethe vacuum erection device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical nutrition therapy services provided on August
30, 2019.
You asked the Plan to pay for medical nutrition therapy services. You say that medically necessary care was
provided to the enrollee. The Plan denied your request. The Plan says the service does not meet the coverage
requirements.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services
only for enrollees with renal disease or diabetes.
The records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the
Plan does not have to pay for the medical nutrition therapy services provided on August 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular disease genetic analysis provided on September 29, 2020.

You asked the Plan to pay for the genetic analysis. You say that this is medically necessary testing. The Plan denied your request. The Plan says this testing is not covered per Medicare rules.

The Plan must follow Medicare rules. Medicare rules say that lab testing must be ordered by the physician who is treating the enrollee for a specific medical problem and uses the results in the management of this medical problem. 

The testing provided is genetic testing for cardiovascular diseases. This testing was ordered by a podiatrist. A podiatrist, a doctor who treats diseases of the feet, cannot use the results of this testing in the management of cardiovascular disease. As such, we find that the Medicare rules for payment of this testing have not been met.

Therefore, we decided that the Plan does not have to pay for the cardiovascular disease genetic analysis provided on September 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 11, 2020.
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 claims were incorrectly billed.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided by an out-of-network provider on February 8, 2021.You asked the Plan to pay forthe office visit. You say that you gave the provider your Medicare information and you thought this was covered.The Plan denied your request. The Plan says in-network providers were available.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. We decided that the Plan does not have to pay forthe office visit provided by an out-of-network provider on February 8, 2021.You asked the Plan to pay forthe office visit. You say that you gave the provider your Medicare information and you thought this was covered.The Plan denied your request. The Plan says in-network providers were available.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 forthe office visit provided by an out-of-network provider on February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exams and services (99214, 92134, 92020) provided on March 12, 2021.
You asked the Plan to waive the copayment for the eye exams and services. You say that you should have a $0 copayment because your contract says that eye refractions have a $0 copay. The Plan denied your request. The Plan says the copayment for these services 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 $40 copayment for Medicare-covered vision services. You have been asked to pay a $40 copayment for the eye exams and services. You state that you should have a $0 copayment as this was an eye refraction, however none of the services provided were billed as an eye refraction in conjunction with a routine eye exam. The services provided were billed as medical eye exams and in conjunction with medical, non-refractive diagnoses. Therefore, the services you received are considered medical Medicare-covered vision services rather than routine supplemental vision care.
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 eye exams and services (99214, 92134, 92020) provided on March 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair added on to an electric seat lift mechanism, for the enrollee.
You asked the Plan to pre-approve the recliner chair. You say that the enrollee currently sleeps in a recliner as they cannot lie flat in bed. You state it has become increasingly difficult for the enrollee to get out of the recliner and has taken two (2) serious falls in the past month. The Plan denied your request. The Plan says Medicare will not pay for the recliner feature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a recliner chair added on to an electric seat lift mechanism, for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound (76705) provided on February 1, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $95 copayment for basic radiological services provided at an in-network, outpatient hospital.

You have been asked to pay a $95 copayment for the radiological service provided. 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 (76705) provided on February 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $10 copayment charged for a telehealth visit provided on August 26, 2020.

You asked the Plan to waive this copayment. You say that you do not believe there should be any cost share for this visit. The Plan denied your request. The Plan says your provider was contacted, and a corrected claim was requested to reflect a $10 copayment. Maximus partially overturned the Plans denial stating the copayment should be reduced from $30 to $10. The Plan requested a reopen and confirmed this had already been done.

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 a $10 copayment for each telehealth visit.

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 $10 copayment charged for a telehealth visit provided on August 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited bilateral noninvasive physiologic studies of upper
or lower extremity arteries (93922) provided on January 19, 2021.
You asked the Plan to pay for the study. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says the diagnosis code submitted is not appropriate for the
service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the study. Our reviewer says that the list of
recognized codes does not include the code used by the provider of services R60 as a code describing medical
necessity. Our physician reviewer found not only is R60 not in the list of recognized symptoms for the study,
but the file does not include attached medical records including medical history and physical exam to
determine if another ICD10 code would have been more appropriate.
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 study have not been met. Therefore, we decided that the Plan does not have
to pay for the limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922)
provided on January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 28, 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 the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for four (4) office visits with a specialist (99213) provided on January 7, 2021, to February 4, 2021.

You asked the Plan to waive the copayment for office visits. You say that the provider never advised you of any cost shares prior to the dates of service. The Plan denied your request. The Plan says the copayment 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 $35 copayment for physician/practitioner services, including doctor's office visits with a specialist.

You have been asked to pay a $35 copayment for each office visit with a specialist ($35 x 4 visits = $140). The EOC confirms that $35 per visit, is the required copayment for this service. 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 four (4) office visits with a specialist (99213) provided on January 7, 2021, to February 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.

You asked the Plan to pre-approve Botox. You say that this request is medically necessary. The Plan denied your request. The Plan says this drug is not covered under your medical benefit.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on June 30, 2020.
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 incorrectly billed.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the appropriate place of service (POS) code. We looked at the file and Medicare rules. The file shows that the services at issue were billed with Place of Service (POS) code 15 for a mobile unit; however the services were received in the facility setting. 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 for the testing services rendered on June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5298) purchased on October 13, 2020.
You asked the Plan to pay for the hearing aids. You say that you feel the Plan mislead you when you signed up for this insurance plan and you did not know you needed to use the Plan's specified provider. The Plan denied your request. The Plan says the hearing aids were not purchased from the Plan's required provider, and therefore payment cannot be made.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are purchased from the specified in-network provider. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's specified hearing network as required by the contract. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5298) purchased on October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON second opinion. You say that the Plan should make an exception and approve the OON consultation because you are not satisfied with the explanation you received from the Plan's in-network doctor when discussing your Glaucoma condition. You say that you do not want your condition to get worse. The Plan denied your request. The Plan says there are in-network providers who can supply second-opinion consultation services for the enrollee's condition.
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 second opinion services at issue in this appeal. We found no exception that would require the Plan to pre-approve OON services. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care (99291) provided on October 23, 2020.
You asked the Plan to pay for critical care. You say that this was billed correctly. The Plan denied your request. The Plan says this is not documented in the records.
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 time spent on this service is not documented in the submitted records. Based on this information, we decided that Medicare rules for
coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99291) provided on October 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator rendered on September 28,
2020.

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 there is no valid proof of delivery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS
suppliers are required to maintain proof of delivery.

We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 for the neuromuscular stimulator rendered on September 28,
2020.