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

We decided that the Plan does not have to waive the copayments for inpatient hospital stays from September 24, 2020, to October 25, 2020.
You asked the Plan to waive the copayments for inpatient hospital stays. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for days 1-7 for inpatient hospital coverage. You had an inpatient hospital stay from September 24, 2020, to September 27, 2020. Therefore, you are responsible to pay a $250 copayment for days 1-3 (September 24, 2020, to September 26, 2020). $250 (copayment) x 3 (inpatient days) = $750. You had an inpatient hospital stay from October 20, 2020, to October 25, 2020. Therefore, you are responsible to pay a $250 copayment for days 1-5 (October 20, 2020, to October 24, 2020). $250 (copayment) x 5 (inpatient days) = $1,250. The total amount you owe is: $2,000. You have been asked to pay the total copayment amount of $2,000 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital coverage 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 copayments for inpatient hospital stays from September 24, 2020, to October 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle Libre 14 Day Sensor (CPT code K0553).
You asked the Plan to pre-approve the sensor. You say that the sensor is necessary. The Plan denied your
request. The Plan says the Medicare criteria were not met.
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.
We looked at the file and Medicare rules. You did not meet the criteria for the requested item because you are
not insulin-treated. Based on this information, we decided that Medicare rules for coverage of the sensor have
not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre 14 Day Sensor
(CPT code K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Intravenous Immune Globulin (IVIG) provided on June 4, 2020.
You asked the Plan to pay for Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg (J1569). You say that the Plan should pay this claim. The Plan denied your request. The Plan says no testing, plan or evaluation for the drug could be found in the available documentation.
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 pay for Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg (J1569).
Our reviewer says that the services were not considered medically reasonable and necessary in this case. Our physician reviewer found as the knowledge of these diseases has improved and expanded, the use of IVIG has proportionally grown. With this, the body of literature supporting the use of IVIG in these situations has equally grown. The literature supports the use of IVIG in acute situations such as prevention of infections in patients with solid organ and bone marrow transplants, myeloma, leukemia, and HIV infections as well as in the acquired and genetic immunodeficiency syndromes such as Chronic inflammatory demyelinating polyradiculoneuropathy. Additionally, the use in blocking damage by toxic antibodies in Guillain-Barr syndrome, pemphigus and its variants has been shown to be effective. The review has determined that the records provided do not support the use of IVIG was appropriate in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg (J1569) have not been met. Therefore, we decided that the Plan does not have to pay for Intravenous Immune Globulin (IVIG) provided on June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
September 18, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.
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 subsequent nursing facility care. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on September 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dry needling physical therapy (CPT code 20561).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found dry needling of trigger points has not been shown to be clinically superior to sham treatment or manual therapy. In addition, dry needling is associated with a high incidence of mild adverse events. The evidence is insufficient to determine the effects of the technology on health outcomes. The review has determined that the items/services at issue in this case are not medically reasonable or necessary. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve dry needling physical therapy (CPT code 20561).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for home health care services provided from May 28, 2020, to July 1, 2020.
You asked the Plan to waive the coinsurance for the direct skilled nursing services of a RN and hospice or home health care services. You say that the enrollee was not aware that they would have to pay out of pocket for the services. The Plan denied your request. The Plan says the coinsurance amount that the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for home health care. The allowed amounts of these claims total $2,065.75, resulting in a total coinsurance amount of $413.15. The enrollee has been asked to pay 20% of the cost for each Medicare-covered home health visit. Home health care falls within the Home Health Agency Care benefit category. 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 coinsurance for home health care services provided from May 28, 2020, to July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on August 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for vision services. You say that you went to the ER but they said they could not help you because of the virus. You say that you would like the Plan to pay for the specialist office visit you required. The Plan denied your request. The Plan says prior authorization was not obtained for these services by a participating provider.
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 vision services provided on August 28, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the ConfirmMDx testing provided on April 13, 2020.
You asked the Plan to pay for the ConfirmMDx testing. You say that the provided ConfirmMDx testing was
medically necessary. The Plan denied your request. The Plan says that the services provided are not covered.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the ConfirmMDx testing. Our reviewer says
that the enrollee meets criteria for the ConfirmMDx testing. Our physician reviewer found the enrollee is with
elevated PSA of 9.1 ng/mL that was evaluated with ultrasound guided needle biopsy on 4/13/20. Fifteen core
biopsies were obtained and were all benign. He also had a negative biopsy in 2018. The enrollee does meet
coverage criteria per the above LCD for the provided ConfirmMDx testing.
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 ConfirmMDx testing have been met. Therefore, we decided that the Plan
has to pay for the ConfirmMDx testing provided on April 13, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services.

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 that the DRG is not supported.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the DRG is not supported by the clinical documentation; however, no medical records were received with the case file. Without medical records, a determination based on the appropriate billing of the DRG cannot be supported. Therefore, we decided that the Plan has to pay for the inpatient hospital services.

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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises, therapeutic activities, evaluation of physical therapy, self-care management training, evaluation of occupational therapy, speech/hearing therapy, evaluation of speech sound production, and evaluation of swallowing function provided from August 27, 2020, to August 31, 2020.
You asked the Plan to pay for the therapeutic exercises, therapeutic activities, evaluation of physical therapy, self-care management training, evaluation of occupational therapy, speech/hearing therapy, evaluation of speech sound production, and evaluation of swallowing function. 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 enrollee's terminal condition.
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 August 17, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises, therapeutic activities, evaluation of physical therapy, self-care management training, evaluation of occupational therapy, speech/hearing therapy, evaluation of speech sound production, and evaluation of swallowing function provided from August 27, 2020, to August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric diagnosis interview examination (90792) provided on September 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychiatric. You say that you depend on the hospital staff to verify eligibility and to obtain proper authorization for in network and out of network providers from the member's insurance. The Plan denied your request. The Plan says with the information provided, the plan cannot determine if a physician's order was given, how the member came to the provider, the referring provider, or whether the services are necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. All providers are required to furnish necessary information to the health plan when requested. After multiple attempts to obtain information, none was received as of this date. We looked at the file and Medicare rules. 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. Based on this information, we decided that Medicare rules for coverage of the psychiatric have not been met. Therefore, we decided that the Plan does not have to pay for psychiatric diagnosis interview examination (90792) provided on September 24, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ultrasound examinations provided on November 9, 2020 and November 18, 2020.
You asked the Plan to waive the copayments for ultrasounds. You say that you have had these services in the past without copayments. The Plan denied your request. The Plan says the copayment amounts you are being charged are 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 $155 copayment for each ultrasound exam. For the ultrasound on November 9, 2020, you have been asked to pay $155 copayment. For the ultrasound on November 18, 2020, you have been asked to pay the allowed amount of $102.17 which is less than the $155 copayment. Your total copayment obligation is therefore $257.17. You have been asked to pay $155 copayment or less for each ultrasound. Ultrasounds fall 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 copayments for ultrasound examinations provided on November 9, 2020 and November 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on June 17, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan states that claim A was denied because the Plan previously paid for this service under another claim B. Both claims were provided for review. Both claims that show this service was billed under the same physician group. Medicare billing requirements states that a distinct services modifier would need to be billed in order to bypass the PTP edit that applied to this claim.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on June 17, 2020 and billed under claim A.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator (E0466).

You asked the Plan to pre-approve the portable ventilator. You say that the enrollee has been using this device since 2019 and needs to continue. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen.

We asked our 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 portable ventilator. Our reviewer says that the service is not necessary. Our reviewer found the requested device is being used in the bilevel PAP mode rather than being used as a home ventilator. The requested ventilation technology is available on an E0471 device. A trial of an E0471 device has not been undertaken. Thus, the denial for an E0466 Home ventilator, any type, used with noninvasive interface, (e.g., mask), which is a mechanical ventilator with functionality that exceeds that of an E0470 or E0471 device, is consistent with Medicare regulations.

We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus Gene panel provided on June 12, 2020.
You asked the Plan to pay for the Tempus Gene panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 Tempus Gene panel at issue in this appeal 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 Tempus Gene panel provided on June 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cardiac stress test and the myocardial perfusion imaging (SPECT scan) you had on July 9, 2020.
You asked the Plan to waive the copayments for the stress test and SPECT scan. You say that you do not agree with these copayments. The Plan denied your request. The Plan says you were charged these copayments 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 non-radiological diagnostic services (including stress tests) and a $150 copayment for radiological diagnostic services (including SPECT tests). You have been asked to pay a $25 copayment for the stress test and a $150 copayment for the SPECT scan. The stress test falls within the non-radiological diagnostic services benefit category and the SPECT test falls within the radiological diagnostic services benefit category. This means that you have been asked to pay the correct amounts 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 copayments for the cardiac stress test and the myocardial perfusion imaging (SPECT scan) you had on July 9, 2020.