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

We decided that the Plan does not have to pre-approve transportation for a skilled nursing facility transfer.
You asked the Plan to pre-approve transportation services. You say that you are at high risk for falling again.
The Plan denied your request. The Plan says you are receiving appropriate services at the facility you are
currently in.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
We looked at the file, and Medicare rules. Coverage is not available for transport from a hospital capable of
treating you because you prefer a specific hospital or physician. Based on this information, we decided that
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to preapprove
transportation for a skilled nursing facility transfer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe shingles vaccine received on September 10, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says this is only covered under Part D prescription drug coverage.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the services.Therefore, we decided that the Plan does not have to pay forthe shingles vaccine received on September 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pay forassistant surgeon services (CPT 27614) provided to the enrollee on June 22, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysan assistant surgeon cannot be paid.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 27614. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the services have not been met.Therefore, we decided that the Plandoes not haveto pay forassistant surgeon services (CPT 27614) provided to the enrollee on June 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for gauze, non-impregnated, sterile (A6402) gauze, impregnated (A6223) specialty absorptive dressing, wound cover, sterile (A6251, A6253) contact layer, sterile (A6207) transparent film, sterile (A6259) tape, non-waterproof (A4450) provided August 10, 2020 to August 12, 2020.
You asked the Plan to waive the copayment for the wound supplies. You say that attempts to take this matter up with the provider have proven futile. You received a bill for $70.74. You believe this is completely unjustified. The Plan denied your request. The Plan says the claim was processed and the correct cost share was applied per the Evidence of Coverage.
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 20% coinsurance for Durable Medical Equipment (DME) and related supplies. You have been asked to pay $70.74 ($353.70 x 20%) for the wound supplies. The wound supplies fall within the Durable Medical Equipment (DME) and related 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 gauze, non-impregnated, sterile (A6402) gauze, impregnated (A6223) specialty absorptive dressing, wound cover, sterile (A6251, A6253) contact layer, sterile (A6207) transparent film, sterile (A6259) tape, non-waterproof (A4450) provided August 10, 2020 to August 12, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveSupartz.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services are not medically necessary.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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has bilateral knee osteoarthritis. Chart notes indicate crepitus in both knees and her pain is worse with walking and standing. She has tried and failed ibuprofen 600 mg, Tramadol, and Diclofenac 1 percent gel for over three months. She had steroid injections on June 20, 2020. She has tried and failed conservative therapies. The records support that Supartz is reasonable and medically necessary and safe and effective for the enrollee.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 been met.Therefore, we decided that the Plan has to pre-approveSupartz.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay fordisposable supplies (A0398) provided on June 14, 2020.You asked the Plan to pay forthe supplies. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this item is included in the base rate for the ambulance service and not paid separately.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 A0398 is not supported in the record. Specifically, supplies are not paid separately for ambulance services are they are included in the base rate. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met.Therefore, we decided that the Plan does not have to pay fordisposable supplies (A0398) provided on June 14, 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 the current facility does not provide enough physical therapy to allow a return to the prior level of functioning. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 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 was admitted from December 25 - December 30, 2020, for a COVID-19 infection and myocardial infarction. He was discharged to skilled nursing facility. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating
provider on August 27, 2020.
You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with these charges.
The Plan denied your request. The Plan says the correct coinsurance has been applied.
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%
coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed
amount is $91.29. The total amount you are being asked to pay is $18.26 ($91.29 x 20% = $18.26). The correct
coinsurance has been applied to the services that were provided. An injection falls within the Medicare Part B
prescription drugs 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 an injection
provided by a participating provider on August 27, 2020.
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 you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 you were hospitalized for diabetic ketoacidosis and respiratory failure secondary to
Covid-19 pneumonia. You are status post tracheostomy tube placement and peg tube placement. Your hospital
course was complicated by seizures and minimal responsiveness despite being off sedation. You do not require
services at the LTACH that are not available at the acute care hospital where you are currently receiving care.
There are no services available at the LTACH that you require that are not available at the health care setting
being offered by the health plan.
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 pre-approve long-term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary and supported by the clinical documentation provided.The Plan denied your request. The Plan says the enrollee is receiving the appropriate inpatient acute care and does not require transfer to an LTACH.

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 there is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the charges forthe comprehensive oral evaluation (D0150) provided on September 25, 2020.You asked the Plan to waive the charges forthe comprehensive oral evaluation. You say that this provider did the work you needed for much lessthan what the other provider was asking.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 thatexceeds 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 September 23, 2020, and your comprehensive oral evaluation (D0150) benefit has been exhausted.Therefore, we decided that the Plan does not have to waive the charges forthe comprehensive oral evaluation (D0150) provided on September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) and the complete series x-ray (D0210) provided on September 28, 2020.You asked the Plan to pay forthe dental services. You say that you went to see a new dentist. You say that your old dentist no longer accepts your plan. You say that the new dentist needed to take x-rays. You also say that it is not your fault that you needed to start at a new dentist.The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 years. The Plan says that complete series x-ray is covered once every 5 years. The Plan also says that the frequency limits have 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 and the services are listed as covered, the frequency limits for these services have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and a complete series x-ray that you received on February 15, 2019.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) and the complete series x-ray (D0210) provided on September 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient services provided from May 1, 2020, to May 6, 2020.You asked the Plan to waive the copayment forthe inpatient services. You say that you cannot afford the copayment.The Plan denied your request. The Plan says you were charged the 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 $393 copayment each day for days 1-5 for Inpatient Hospital Care. You have been asked to pay a $393 copayment each day for days 1-5 for the inpatient services. The inpatient services fallwithin 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 forinpatient services provided from May 1, 2020, to May 6, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan does not have to pay for drug testing services provided April 11, 2019 to May 20,
2020 billed under codes 80307 and G0483.
You asked the Plan pay for these services. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says while part of the services were paid, the Plan cannot pay codes 80307 and
G0483 because they were not billed correctly. Maximus overturned the Plans denial. The Plan requested a
reopen and stated that while they are working with the provider to get a corrected claim and you are not
financially responsible for the denied services, Medicare guidelines do not allow them to pay the provider for
these codes.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case codes 80307
and G0483 cannot be paid as billed due to the CLIA edit rules. The Plan is working with the provider to make
sure you are not balance billed for these services. Therefore, we decided that the Plan does not have to pay for
drug testing services provided April 11, 2019 to May 20, 2020 billed under codes 80307 and G0483.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services with CPT code 99253 provided on
July 7, 2020.
You asked the Plan to pay for CPT code 99253. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says the services are not covered as billed.
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 looked at the file and Medicare rules. In this case, CPT code 99253 has a status code of "I" under the
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses
another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have
to pay for the physician services with CPT code 99253 provided on July 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea transit securement package.You asked the Plan to pre-approvethe transit securement package. You say that you would like reconsideration because these tie downs are necessary to safely transport the member.The Plan denied your request. The Plan says Medicare does not pay for precautionary or self-help equipment.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea transit securement package.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea cervical/thoracic interlaminar epidural injection for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthe notes from the doctor did not show a pain level of at least 6/10.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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of neck pain with radicular symptoms. However, there was no documentation of the visual analog scale (VAS) pain score provided. Guidelines recommend the requested procedure when the pain is at least 6/10. The review has determined that the requested cervical/thoracic interlaminar epidural is not medically necessary or reasonable.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 not been met.Therefore, we decided that the Plandoes not haveto pre-approvea cervical/thoracic interlaminar epidural injection for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is 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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.