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

We decided that the Plan does not have to pay for intermittent limb compression device.

You asked the Plan to pay for intermittent limb compression device. You say that this device was medically necessary for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare when a six-month trial of conservative therapy has not been completed.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. The rules also state that for chronic venous insufficiency there must be a documented six-month trial of conservative therapy.

The file does not show that the enrollee has completed a six-month trial of conservative therapy. This trial is not discussed anywhere in the medical records and there is no evidence of it having been completed. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued services at a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is medically stable and can transition to long term care.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued services at a skilled nursing facility (SNF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the outpatient surgery.

You asked the Plan to reduce the copayment for the outpatient surgery. You say that this should be considered an inpatient procedure because you were in the hospital longer than 24 hours. You say that you were in a regular hospital room, so this shouldn't be considered outpatient. The Plan denied your request. The Plan says you were charged this copayment 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 $450 copayment for outpatient surgery.

Medical records from this procedure clearly indicate that you were not admitted as an inpatient to the hospital. The records show that you had ambulatory (i.e., outpatient) surgery on this date. Your doctor did not order inpatient admission for you. You have been asked to pay a $450 copayment for the outpatient surgery. the outpatient surgery falls within the outpatient surgery 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 reduce the copayment for the outpatient surgery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Myriad myRisk panel.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.

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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of personal history of malignant neoplasm of the breast. The case file does not contain clinical medical records for the enrollee. Consequently, it cannot be determined that the Myriad myRisk panel was reasonable and medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the Myriad myRisk panel.

Local Coverage Determination (LCD) L36163 referenced by the Plan is not valid for the services at issue and was not used in the Maximus determination.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing.

You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denied coverage for all cardiovascular risk assessment panels except the basic lipid panel.

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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.

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 did not specify whether the ordering provider was in-network or out-of-network with the Plan. The documentation does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for laboratory testing.

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: Unfavorable

We decided that the Plan does not have to pay for the radiation treatments.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 radiation treatments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the enrollee could have been treated by an in-network 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 the medical services provided on September 19, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement of nails, by any method (11721) provided on
October 5, 2020, by an OON provider.
You asked the Plan to pay for the Podiatry services. You say that the enrollee is a resident in a nursing home
and has an authorization on file for all care at the facility including consultations. 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 debridement of nails, by any method (11721)
provided on October 5, 2020, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for abscess drainage (10061) provided on September 5, 2019.
You asked the Plan to pay for abscess drainage. You say that this was medically necessary. The Plan denied your request. The Plan says there is a more appropriate code for the procedure performed.
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 10061 is incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple. We find that CPT code 10061 is not supported in the medical record. Specifically, the record indicates a single, uncomplicated abscess drainage was performed. Based on this information, we decided that Medicare rules for coverage of abscess drainage have not been met. Therefore, we decided that the Plan does not have to pay for abscess drainage (10061) provided on September 5, 2019.
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 IRF admission is medically necessary. The Plan
denied your request. The Plan says your needs can be met at a different level of care.

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 based on the medical records provided 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 may require skilled physical therapy and occupational therapy but based on the
medical records provided It is not clear you would be able to fully benefit and/or participate in an IRF 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the inhalation of nitrous oxide (D9230) provided on January
22, 2020.
You asked the Plan to pay for the dental service. You say that this claim was charged to your dental plan. You
say that the oral surgery should be charged to your medical plan, not dental. You say that your dental coverage
has been depleted. You say that you have dental charges that are not paid. You also say that the dental charge
should be removed and charged to your medical plan. The Plan denied your request. The Plan says the services
you received are dental in nature. The Plan says that there is an allowance of $2,000 for covered dental
services. The Plan also says that the $2,000 allowance has been exceeded.
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 $2,000 allowance has been
exceeded.
The Evidence of Coverage clearly states that you are responsible for any amount above the dental coverage
limit. The record shows that the services you received were for the treatment of tooth # 31. Additionally, 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 the inhalation of nitrous oxide
(D9230) provided on January 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the simple extraction, two surgical extractions, and
immediate maxillary partial denture provided on November 11, 2020.
You asked the Plan to pay for the extractions and immediate maxillary partial denture. You say that you
thought these services would be covered. The Plan denied your request. The Plan says the annual limit allowed
by your dental plan for the 2020 benefit year has been 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $1,000 allowance
every year for Non-Medicare-covered preventive and comprehensive dental services combined. The contract
clearly states that you are responsible for any amount above the dental coverage limit. The record shows that
you met the annual maximum benefit while processing this claim for the November 11, 2020, date of service
and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to
pay for the simple extraction, two surgical extractions, and immediate maxillary partial denture provided on
November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for thyroid stimulating hormone testing (84443) provided on August 3, 2020.
You asked the Plan to pay for thyroid stimulating hormone testing. You say that your physician recommended that you get this testing annually. The Plan denied your request. The Plan says this was performed for screening purposes and you were informed it would not be covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, thyroid stimulating hormone testing, 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 thyroid stimulating hormone testing (84443) provided on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) provided on October 27, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the hospital outpatient clinic visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were provided without a referral and did not meet OON criteria for coverage.
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 hospital outpatient clinic visit (G0463) provided on October 27, 2020, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital visit (G0463) provided by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that you received other services that were pre-approved for this provider and were then instructed to return for a follow-up. The Plan denied your request. The Plan says they only cover out-of-network services in certain circumstances. The follow-up was not urgent or pre-approved and could have safely been provided in-network.

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 outpatient hospital visit (G0463) provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated scooter.

You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a home evaluation.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found the records do not detail how your mobility deficit impairs MRADLs in the home. You currently use a walker. The documentation does not reveal that your home is accessible to use a power scooter.

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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99204) trigger point injection (20553) provided on October 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that the claim denied for missing authorization. Resubmitting the claim with supporting documentation to support CPT code 20553, 99204, 25. Please review and reprocess for payment. 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 outpatient office visit (99204) trigger point injection (20553) provided on October 7, 2020 by an out of network (OON) provider.