Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative 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 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 waive the copayment for the destruction of facet joint nerves provided on December 8, 2020.

You asked the Plan to waive the copayment for the destruction of facet joint nerves. You say that there was no surgery, there was only one injection. You say you cannot afford this copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $350 copayment for Medicare-covered in-network outpatient surgery services furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location.

The enrollee has been asked to pay a $350 copayment for the destruction of facet joint nerves. The destruction of facet joint nerves falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were only charged for one injection. The injection is considered a surgical procedure.

This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the destruction of facet joint nerves provided on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99291) provided February 13, 2021 to
February 15, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the documentation does not support the billed services.
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 visit of 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not note how
much time was spent on this service. Based on this information, we decided that Medicare rules for coverage of
the physician services have not been met. Therefore, we decided that the Plan does not have to pay for
physician services (99291) provided February 13, 2021 to February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous ambulatory peritoneal dialysis (CAPD) provided from November 1, 2020 to November 30, 2020.

You asked the Plan to pay for CAPD (90945). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the maximum has already been allowed for these services.

The Plan must follow Medicare rules. Medicare rules say that training services and supplies that are covered under the composite rate include personnel services, dialysis supplies and parenteral items used in dialysis, written training manuals, material and laboratory tests. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CAPD (90945) have not been met. The maximum reimbursable CAPD training sessions has been met. Therefore, we decided that the Plan does not have to pay for continuous ambulatory peritoneal dialysis (CAPD) provided from November 1, 2020 to November 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a continuous glucose monitor (CGM) (K0553).
You asked the Plan to preapprove the CGM. You say that you require this device. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections.
Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a continuous glucose monitor (CGM) (K0553).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 26, 2021.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on February 6, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for laboratory services provided on February 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (88305) rendered by the out-of-network (OON) provider on January 13, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (88305) rendered by the out-of-network (OON) provider on January 13, 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 care is medically necessary. The Plan denied
your request. The Plan says a lower level of care can meet your needs.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was
admitted for syncope, peripheral artery disease and chronic foot ulcers. He had revascularization of legs and
amputation of affected toes. Medical problems are stable. There are no complex nursing or rehabilitation needs.
While the documentation does support a need for physical and/or occupational therapy, there is no documented
need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this
patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency department visit for the evaluation and management of the enrollee represented by code 99283 provided on November 4, 2020.

You asked the Plan to pay for code 99283. You say that the medical records support the billing of code 99283. The Plan denied your request. The Plan says that the medical records do not support the billing of code 99283.

The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect the services provided. 

In this case, you billed CPT code 99283. The definition of CPT code 99283 is an emergency room visit for the evaluation and management of a patient which requires three components (taking into account the urgency of the clinical condition or the patient's mental status):

1. An expanded problem focused history; 
2. An expanded problem focused examination; and 
3. medical decision making of moderate complexity.

In addition, CPT code 99283 usually includes a presenting medical problem of moderate severity.

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 code 99283 Our reviewer says that the medical records support the billing of code 99283. Our physician reviewer found the record indicates that the enrollee was evaluated for increased dizziness and has an established diagnosis of dizziness. The enrollee also had a complaint of chest pain with radiation to the left arm. Physical examination revealed a positive Dix-Hallpike test. The enrollee was found to be hyponatremic. A decision was made to admit the enrollee to telemetry. The record documents three diagnosis. The data reviewed included laboratory, radiological, and indicates that the history was obtained from someone other than the enrollee. The record reflects moderate complexity decision making. The elements of the coverage rule are satisfied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 99283 have been met. Therefore, we decided that the Plan has to pay for the emergency department visit for the evaluation and management of the enrollee represented by code 99283 provided on November 4, 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on July 14, 2020.
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not agree with this. You say that this copayment needs to be paid. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $90 copayment for emergency care.
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls within the emergency care 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 room visit provided by a participating provider on July 14, 2020.
Your quality-of-care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) complete lower denture (D5120) provided January 27, 2020.

You asked the Plan to pay for the dental services. You say that you had a set of dentures put in by this provider and you paid $550 for this service. You are trying to get reimbursed for this expense. The Plan denied your request. The Plan says dentures are not covered under the Plan 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. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) complete lower denture (D5120) provided January 27, 2020.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs physical, occupational and special therapy. The Plan denied your request. The Plan says that records do not show that the enrollee requires physician supervision by a rehab doctor at least 3 days per week, requires an intensive and coordinated interdisciplinary approach to rehab, if the enrollee's rehab is complex, or if the enrollee would be able to actively participate safely in 3 hours of therapy 5 days a week or 15 hours of therapy a week.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a
scheduled total hip replacement. The enrollee's medical problems are stable. There are no complex nursing or
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation
does support a need for physical and/or occupational therapy, there is no documented need for a intensive,
multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram, routine ECG with at least 12 leads (93000) provided on November 2, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the electrocardiogram. You say that please see the attached medical records that show medical necessity. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 electrocardiogram, routine ECG with at least 12 leads (93000) provided on November 2, 2020 by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve L3 prosthesis components (L5981 and L5986).

You asked the Plan to pre-approve the prosthesis components. You say that these components are necessary. The Plan denied your request. The Plan says these components exceed the enrollee's need.

The Plan must follow Medicare rules. Medicare rules say that L5981 does not represent a complete foot. It is part of a foot that must be paired with a complete foot based on member's functional classification. The vendor indicates that the member's "expected beneficiary functional level" is K3, which is not supported by the documentation. There must be clear documentation why this part is needed, which has not been provided. While L5968 is requested, L5968 does not represent a complete foot. It is part of a foot that must be paired with a complete foot based on member's functional classification. Therefore, it cannot be covered until it is paired with the appropriate code.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the prosthesis components have not been met. Therefore, we decided that the Plan does not have to pre-approve L3 prosthesis components (L5981 and L5986).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can safely continue to receive the services you need in a skilled nursing facility.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.