Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (12001) provided on December 11, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
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 12001 is "Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less". We asked our coding 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 services. Our reviewer says that the use of code 12001 is not supported by the records provided. Our coding reviewer found that the record indicates
that the enrollee presented to the emergency room with oozing from a temporal excisional biopsy site. Pressure was applied. The provided documentation does not indicate that a simple repair of superficial wound was performed. The elements of the coverage criteria are not satisfied. 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 the services (12001) provided on December 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 12, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were not aware of the frequency limitation for this service. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on January 21, 2020 and your comprehensive oral evaluation (D0150)
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory drug testing (81291) provided on October 13, 2020, by an out of network (OON) provider.
You asked the Plan to pay for laboratory drug testing. You say that the services were medically necessary. The Plan denied your request. The Plan says members must use in network providers to get medical care and 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 laboratory drug testing (81291) provided on October 13, 2020, by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six additional physical therapy (PT) visits.
You asked the Plan to pre-approve the additional PT visits. The Plan denied your request. The Plan says additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had extensive prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part of a maintenance program. 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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve six additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9500) provided from May 11, 2020,
to July 5, 2020.
You asked the Plan to pay for home infusion therapy. You say that these services should be processed as innetwork
services. The Plan denied your request. The Plan says these services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code S9500 is not supported in the medical record. Specifically, this code has a status
indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this
information, we decided that Medicare rules for coverage of home infusion therapy have not been met.
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9500) provided from
May 11, 2020, to July 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF is medically necessary, as a lower level of care cannot provide the enrollee with the interdisciplinary approach required to return the enrollee to full function. The Plan denied your request. The Plan says the necessary medical care is routine and does not require a team of providers. These services can safely be provided in other settings.
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different 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 an additional amount for a filling (D2140) provided on February 22, 2021.
You asked the Plan to pay an additional amount for a filling. You say that you would like the Plan to pay an additional amount towards the service. 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 filling 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 filling (D2140) provided on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment (E0675) received on January 11,
2021.
You asked the Plan to pay for the equipment. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not covered at this place of service.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.
Records show that the equipment was used in an ambulatory surgical center (place of service 24). Therefore,
we decided that the Plan does not have to pay for durable medical equipment (E0675) received on January 11,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pacemaker evaluation provided by an out-of-network
provider on February 1, 2021.
You asked the Plan to pay for the pacemaker evaluation. You say that the patient is unable to seek the correct
primary care physician to sign their orders. You say that the services were medically necessary, and the claim
should be reconsidered for payment. The Plan denied your request. The Plan says this provider is not a network
provider with the Plan and the services were not approved in advance.
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
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 pacemaker evaluation provided by an out-ofnetwork
provider on February 1, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient hospital admission and care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary because the enrollee could have a stroke at any time. The Plan denied your request. The Plan says that the enrollee can be treated at a lower level of care, such as a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient care are met in this case. Our physician reviewer found the review indicates that the record shows that it is reasonably expected that the patient will require medically necessary hospital care that spans two midnights. Although the sepsis and acute problem has resolved, the Central Nervous System (CNS) problem is chronic and is to be treated with supportive 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pre-approve acute inpatient hospital admission and care.
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 waive the coinsurance for the lab services provided at an in-network outpatient hospital on March 17, 2021.
You asked the Plan to waive the coinsurance for the lab services. You say that the enrollee was not told he was getting labs done and did not have an opportunity to choose to have them done elsewhere. The Plan denied your request. The Plan says this coinsurance was charged correctly. The Plan also stated that it has waived the $250 copayment charged for nuclear medicine services on the same date of service, so the only issue in dispute is the coinsurance for the lab services.
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 lab services in an outpatient hospital.
The enrollee has been asked to pay 20% coinsurance for the lab services. This coinsurance applies regardless of why the labs were performed. 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 the lab services provided at an in-network outpatient hospital on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an extraction (D7210) provided on March 9, 2021.
You asked the Plan to pay for an extraction. You say that you do not understand why the Plan will not cover
the service and you want the Plan to pay. The Plan denied your request. The Plan says the service at issue is not
a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an
extraction (D7210) provided on March 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
You asked the Plan to pre-approve continued inpatient psychiatric services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee was not shown to be a danger to themself or others. The enrollee was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. This enrollee was not showing any aggressive behaviors, or any treatment required for acute threats of safety. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report rendered on November 18, 2020.
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 procedure code 93010 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 93010 (EKG interpretation and report) and 31500 (emergency endotrachel intubation). Code 93010 is a column II code with a modifier indicator of 1 when billed
with column I code 31500. Code 93010 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report rendered on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on January 19, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 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 subsequent nursing facility care provided on January 19, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intrauterine device (IUD) for the enrollee.

You asked the Plan to pre-approve an IUD. You say that an IUD is necessary for vaginal bleeding. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria for an IUD which requires documentation in the medical record of specific clinical circumstances evidencing this medical necessity. Based on the records provided, those criteria are not met. While an IUD may be beneficial for treatment of the enrollee, the documentation does not meet the required criteria. Therefore, we decided that the Plan does not have to pre-approve an intrauterine device (IUD) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery.
You asked the Plan to pre-approve Vertiflex superion device placement surgery. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 pre-approve Vertiflex superion device placement surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has neurogenic claudication with spinal stenosis. The Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vertiflex superion device placement surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on January 25, 2021.
You asked the Plan to pay for lab tests. You say that the medical records you have submitted are sufficient to
make a determination of medical necessity. The Plan denied your request. The Plan says the denial of payment
for this testing is correct, because this testing was not ordered or approved by the enrollee's treating physician.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.
The file does not contain documentation of an established relationship between the enrollee and the ordering
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing
provided on January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair repairs.
You asked the Plan to pre-approve the repairs. You say that this repair order was wrongfully denied. The Plan denied your request. The Plan says Medicare does not cover repairs when the expense for repairs exceeds the estimated expense for replacement of the wheelchair.
The Plan must follow Medicare rules. Medicare rules say that DME repairs are not covered when the cost for repair exceeds the cost of replacement. The cost of repairing the wheelchair would be $8,585,10. There have been previous repairs on the wheelchair, that, when combined with the current cost of repair, would equal $20,496.26. The cost of replacing the wheelchair would be an allowed amount of $9793.29. Based on this information, we decided that Medicare rules for coverage of the repairs have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair repairs.