Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided by a licensed marriage and family therapist on August 4, 2020.
You asked the Plan to pay for services from this type of provider. You say that these services should be
covered by the plan. The Plan denied your request. The Plan says outpatient mental health care provided by a
licensed marriage and family therapist is not covered by Medicare.
The rules say a plan must disclose to its enrollees in clear, accurate terms all benefit information. Your Plan
contract clearly outlines the requirements for outpatient mental health care. The provider used is not the type of
provider covered by the Plan or by Medicare for this type of care. Therefore, we decided that the Plan does not
have to pay for outpatient mental health care provided by a licensed marriage and family therapist on August 4,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on November 11, 2020.

You asked the Plan to pay for a bone replacement graft. You say that you want the Plan to pay for the service. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on November 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve continued services. You say that you are still very weak. The Plan denied your request. The Plan says there are no daily nursing or therapy needs.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued services. Our physician reviewer found that you have skilled nursing needs in the form of wound care. You do not have skilled therapy needs. You do not require necessary services on an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81401, 81403, 81404, 81405, 81406, 81407, 81408) provided on February 5, 2021.

You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with the correct place of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81401, 81403, 81404, 81405, 81406, 81407, 81408) provided on February 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone marrow aspiration.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says medical studies have not proven this procedure helpful for treatment of the enrollee's health problem.
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 requested services. Our physician reviewer found that bone marrow aspirate remains experimental in cases of spinal fusion for use as bone graft. More research is needed to show safety and efficacy.
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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a bone marrow aspiration.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the 5% coinsurance charged for ambulance transport provided on February 15, 2021.

You asked the Plan to waive this coinsurance. You say that you do not believe this coinsurance is correct. The Plan denied your request. The Plan says this coinsurance was charged based on the claim submitted the provider and your Plan contract agreement.

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 5% coinsurance for each one-way ambulance transport. 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 5% coinsurance charged for ambulance transport provided on February 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that your discharge plan remains uncertain. You say that you need extensive assistance with activities of daily living and daily tasks. The Plan denied your request. The Plan says the requirements for approval of SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. At this point, the enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
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 be managed at a lower level of care such as 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 shortness of breath, right upper quadrant pain and a recent right ankle injury. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device provided on January 11, 2020.

You asked the Plan to pay for the pneumatic compression device (E0676). You say that the device was medically necessary. The Plan denied your request. The Plan says PCDs are not covered by Medicare to prevent deep vein thrombosis during and/or following surgery in any setting.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.

This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device provided on January 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (CPT 99291) provided to the enrollee on March 26, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 99291 (1 unit) remains 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 "evaluation and management of the critically ill or critically injured patient, first 30-74 minutes." We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that after a careful review of the evaluation and management documentation, the total time of critical care was not documented. Per CPT guidelines "Code 99291 is used to report the first 30-74 minutes of critical care on a given date. It should be used only once per date even if the time spent by the individual is not continuous on that date. Critical care of
less than 30 minutes total duration on a given date should be reported with the appropriate
evaluation/management code". The documentation did not include time and therefore cannot be verified if
more than 30 minutes were spent.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for critical care services (CPT 99291) provided to the enrollee on March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus and diphtheria vaccine you received on April 1, 2021.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not a covered under Part B.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules.
The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus and diphtheria vaccine you received on April 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Keytruda.

You asked the Plan to pre-approve Keytruda. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee does not meet the requirements for use of Keytruda.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Keytruda. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Keytruda. Our physician reviewer found Keytruda is not Food & Drug Administration approved for the enrollee's diagnosis. The requested use is not supported by one of the major drug compendia or by research appearing in a Medicare-approved medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), bite wing radiographic images (D0274), and a teeth cleaning (D1110) provided on March 11, 2021.

You asked the Plan to pay an additional amount for a periodic oral evaluation, bite wing radiographic images, and a teeth cleaning. You say that you want the Plan to pay an additional amount for these services. The Plan denied your request. The Plan says the claims for these services were processed correctly with the applicable out-of-network allowable amount paid.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation (D0120), bite wing radiographic images (D0274), and a teeth cleaning have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Any amount beyond the allowed amount is your contractual responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), bite wing radiographic images (D0274), and a teeth cleaning (D1110) provided on March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal cleaning and to pay more for the periodic oral exam provided on April 13, 2021 by an OON provider.

You asked the Plan to pay for the periodontal cleaning or pay more for the periodic oral exam. You say that the medical benefits chart substantiates coverage for these services. The Plan denied your request. The Plan says periodic oral exams are covered at a 50% coinsurance for OON providers. The Plan also says that periodontal treatments are not covered by your plan.

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 periodontal cleaning is not among those covered under this benefit. The contract also says that you are responsible for a 50% coinsurance for periodic oral exams that are received out-of-network. Therefore, we decided that the Plan does not have to pay for the periodontal cleaning and to pay more for the periodic oral exam provided on April 13, 2021 by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical and occupational therapy evaluation provided on February 13, 2021.
You asked the Plan to waive the copayment for the physical and occupational therapy evaluation. You say that you did not have therapy; you were only evaluated to see if you needed it done. You say that you should only have to pay the copayment if you had a therapy service done. The Plan denied your request. The Plan says the copayments 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 $25 copayment for Medicare-covered physical, occupational, and speech language therapy visit.
You have been asked to pay a $25 copayment for the physical therapy evaluation and a $25 copayment for the occupational therapy evaluation. The physical and occupational therapy evaluation fall within the "Outpatient rehabilitation services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the physical and occupational therapy evaluation provided on February 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine disposable supplies (A0382 and A0398) and ambulance response and treatment with no transport (A0998) provided on November 19, 2020.
You asked the Plan to pay for the routine disposable supplies and ambulance response and treatment with no transport. You say that you passed out while watching television and your husband called 911. You also say that you were asked if you wanted to go to the hospital and you said no. The Plan denied your request. The Plan says these services are not covered benefits under your plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 19, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the routine disposable supplies (A0382 and A0398) and ambulance response and treatment with no transport (A0998) provided on November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown re-cement provided on April 13, 2021.

You asked the Plan to pay for the crown re-cement. You say that the dentist ran out of time, so you were given another appointment on April 13, 2021 to recement the crown. You say that this was necessary, and insurance should help pay to put it back in your mouth. The Plan denied your request. The Plan says your annual maximum dental benefit was exhausted.

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, you also have a maximum benefit of $500 each year for comprehensive and preventive dental services. The Plan paid $500 toward the dental services received on March 9, 2021 and April 13, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the crown re-cement provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy for the enrollee.
You asked the Plan to pre-approve HBO therapy. You say that this treatment is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for hyperbaric oxygen
therapy (HBOT). The Maximus Physician Reviewer determined that the enrollee had non-healing wounds with
arterial and venous insufficiency. The reviewer stated that the nature, ongoing therapy, and severity of these
lesions made HBO therapy medically reasonable and appropriate and risk of limb loss is noted. The Plan
requested a reopen and argues that the enrollee did not have a covered indication for this service. The medical
records show the enrollee is a 69-year-old man who previously underwent femoral-popliteal bypass surgery.
The enrollee presented to the hospital on October 14, 2020 with cellulitis of his left leg. IV antibiotics were
administered. The enrollee has type 2 diabetes with foot ulcer, and non-pressure chronic ulcer of left heel and
midfoot with necrosis of muscle, with multiple left lower extremity wounds. Hyperbaric oxygen was ordered.
However, the Plan is correct in this case. The enrollee did not have a covered indication for HBOT as
established by NCD 20.29. In addition, chronic peripheral vascular insufficiency is a non-covered indication.
Therefore, Medicare coverage criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not
have to pre-approve hyperbaric oxygen (HBO) therapy for the enrollee.