Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided June 7, 2019.
You asked the Plan to pay for the orthoses. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided June 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves (E0667).
You asked the Plan to pre-approve a pneumatic compression device and sleeves. You say that you have leg problems and this will prevent you from having surgery. The Plan denied your request. The Plan says that the record sent by your provider indicates that you have not had a four week trial of an E0650 or E0651.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves (E0667).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the hip replacement provided on June 4, 2019.
You asked the Plan to waive the coinsurance for the hip replacement. You say that you elected to have your surgery performed by your orthopedic surgeon. You say that you do not agree with the out-of-network limits. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% per stay for each medically necessary covered out-of-network inpatient stay. You have been asked to pay a total of $7,222.81 for the hip replacement.
Date of Service
Provider
Allowed Amount
Coinsurance
Member Liability
June 4, 2019
Surgeon
$1,443.99
50%
$721.99
June 4, 2019
Hospital
$13,001.64
50%
$6,500.82
TOTAL:
$7,222.81
The hip replacement falls within the "Inpatient hospital 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 coinsurance for the hip replacement provided on June 4, 2019.
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 the enrollee cannot be adequately cared for in the current hospital. The Plan denied your request. The Plan says the enrollee is receiving appropriate care in the current setting.
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 enrollee is currently undergoing treatment at an acute care hospital (ACH) following surgery for a subdural hemorrhage. The enrollee was intubated/ventilated upon presentation. He subsequently received a tracheotomy and is tolerating being on a tracheotomy collar. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from June 4, 2019 to July 11, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the
charges based on the quality of care received. 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 $215
copayment per day for days 1-7 for inpatient hospital care.
You had an inpatient hospital stay from June 4, 2019 to July 11, 2019. Therefore, you are responsible to pay a
$215 copayment for days 1-7 (June 4, 2019 to June 10, 2019). $215 (copayment) x 7 (inpatient days) =
$1,505.00.
You have been asked to pay the total copayment amount of $1,505.00 for an inpatient hospital stay. An
inpatient hospital stay falls within the inpatient hospital 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 inpatient hospital stay from June 4, 2019 to July 11, 2019.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and outpatient lab services provided on July 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there are multiple in-network providers within 30 miles of the member's residence that could have rendered these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit and outpatient lab services provided on July 26, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hip x-ray provided on July 24, 2019.
You asked the Plan to waive the copayment for the hip x-ray. You say that you have not had a copayment before. You say that you were not advised of the additional copayment. The Plan denied your request. The Plan says the copayment 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 $20 copayment for each Medicare-covered standard x-ray service. You have been asked to pay a $20 copayment for the hip x-ray. The hip x-ray falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the hip x-ray provided on July 24, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for a good health sauna (A9270) provided on September 2, 2019.
You asked the Plan to pay for the good health sauna. You say that the sauna is medically necessary it is used to detoxify lead from your blood. The Plan denied your request. The Plan says the sauna does not meet the definition of durable medical equipment and is a non-covered service under the Plan.
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 pay for a good health sauna (A9270) provided on September 2, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental health services (90834) provided on August 1, 2019.
You asked the Plan to waive the copayment for the outpatient mental health services. You say that the copayment should be waived. The Plan denied your request. The Plan says the plan has already reimbursed for the allowable amount. The proper cost share has been applied. The plan is not responsible for amounts over the Medicare allowable 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 $10 copayment for Outpatient Mental Health office visits. You have been asked to pay a $10 copayment for the outpatient mental health services. The outpatient mental health services fall within the Outpatient Mental Health - office visits 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 outpatient mental health services (90834) provided on August 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on October 21, 2019.
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that that this is your yearly exam and you feel you should not be charged just because you had a cancer diagnosis two years ago. The Plan denied your request. The Plan says you have been charged 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). Your contract with the Plan clearly says that you must pay a $50 copayment for each basic imaging service (e.g., general x-rays or ultrasound). You have been asked to pay a $50 copayment for the diagnostic mammogram. The diagnostic mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows a personal history of malignant neoplasm which makes the mammogram diagnostic in nature.
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 diagnostic mammogram provided on October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an expandable controller (E2311).
You asked the Plan to pre-approve an expandable controller. You say that this item is needed due to the enrollee's weak upper extremity strength. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that say that an expandable controller is capable of accommodating one or more of the following additional functions: - Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) - Non-proportional input devices (e.g., sip and puff, head array, etc.) - Operate 3 or more powered seating actuators through the drive control. 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 an expandable controller. Our reviewer says that the requested item is considered medically reasonable and necessary in this case. Our physician reviewer found the expandable controller is being requested to control features including the power tilt system with the member having significant upper extremity weakness including shoulder, elbow, and wrist/hand weakness that would be expected to prevent him from being able to control these features without use of a joystick.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller have been met. Therefore, we decided that the Plan has to pre-approve an expandable controller (E2311).
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve intravenous immune globulin injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee's IgG level is greather than 200mg/dl, and there is no evidence of a response to the pneumonia vaccine.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 pre-approve the injection. Our reviewer says that the requested injection is medically reasonable and necessary. Our physician reviewer found the enrollee has diagnoses of common variable immune deficiency,supported by low levels of IgG, and bronchiectasis with frequent bornchitis and pneumonia. She did not respond across the board to a recent pneumococcal vaccine. The enrollee does meet the criteria for this injection. 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 injection have been met. Therefore, we decided that the Plan has to pre-approve intravenous immune globulin injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a VisionCheck device.
You asked the Plan to provide a VisionCheck device. You say that you are homebound and would be able to do your own yearly eye exams with this device. The Plan denied your request. The Plan says this device is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. This item is not considered durable medical equipment per Medicare rule and does not require a prescription by a medical provider. Also, the provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to provide a VisionCheck device.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an office visit (99214) provided on October 3, 2019.
You asked the Plan to pre-approve the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that payment for routine post-surgical care, within 90 days following a radical prostatectomy, is included in the payment for the original procedure.
The Plan must follow Medicare rules. Medicare rules say that services that are not considered part of the global surgery package include services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the office visit have been met. Specifically, the services rendered on October 3, 2019 were provided by another physician. There is no record of an agreed upon transfer of care in the documentation submitted. Therefore, we decided that the Plan has to pre-approve an office visit (99214) provided on October 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs nutritional management, labs, rehab therapy, and daily physician visits. The Plan denied your request. The Plan says the enrollee's needs are being provided at the current level of care.
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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for pancreatitis and related complications. The enrollee is receiving tube feeds and a prolonged course of antibiotics. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on August 2, 2019.
You asked the Plan to pay for the knee orthosis (L1851) and suspension sleeve (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services were not met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on August 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on April 29, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted 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 drug testing rendered to the enrollee on April 29, 2019.