Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided on September 8, 2020, to October 6, 2020 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that since the member was subsiding in a nursing facility, you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not 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 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 forskilled nursing services provided on September 8, 2020, to October 6, 2020 by an out of network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 8, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says there is no authorization for this service and the provider is non-contract.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 providerwith the Plan. The Plan did not pre-approve the laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on July 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF whenthe four factors listed above 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee does not have documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs. The enrollee is independently mobile. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practicalmatter, can be provided at a lower 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 admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran MRI provided on September 18, 2020.You asked the Plan to waive the copayment foran MRI. You say that you were not aware you would owe a copayment and cannot afford the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $180 copayment for advanced imaging services provided in a physician's office or freestanding facility. You have been asked to pay a $180 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you havebeen 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 foran MRI provided on September 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecompression stockings identified with code A6549.You asked the Planto pre-approvethe compression stockings. You say that the longer this takes, the longer you have to go without assistance and comfort.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plandoes not haveto pre-approvecompression stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on July 13,
2020.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the copayment was 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 $35
copayment for per visit to a specialist.
Review of the file shows that you received specialist services on July 13, 2020. You have been asked to pay a
$35 copayment for these services. These services fall within the visit to a specialist 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 specialist services rendered on July 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external female urinary catheter (A4327).

You asked the Plan to pre-approve an external female urinary catheter.You say that the enrollee needs an external female urinary catheter. The Plan denied your request. The Plan says there is no documentation of permanent urinary incontinence. 

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. The medical record does not support medical necessity for an external catheter. Based on this information, we decided that Medicare rules for coverage of the brand specific catheter. have not been met.Therefore, we decided that the Plan does not have to pre-approve an external female urinary catheter (A4327)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe automatic external defibrillator (AED) rendered on June 18, 2020.You asked the Plan to pay forthese services. You say that the services were rendered in good faith.The Plan denied your request. The Plan says the services are not covered.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 these services were used while the enrollee was under inpatient hospital status.Therefore, we decided that the Plan does not have to pay forthe automatic external defibrillator (AED) rendered on June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on June 8, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for these services was not filed until November 3, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe services rendered on June 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not haveto pre-approvetherapy services (97124 and 97140) to be provided by a licensed acupuncturist.You asked the Plan to pre-approvethe therapy services. You say that you would like reconsideration because these therapy services are necessary to provide treatment for your chronic pain.The Plan denied your request. The Plan says services from the requested provider are not a covered benefit.The Plan must follow Medicare rules. Medicare pays for outpatient rehabilitation therapy services only when they are provided by those trained specifically in physical therapy, occupational therapy or speech-language pathology. You are requesting therapy services from a licensed acupuncturist.Therefore, we decided that the Plan does not have to pre-approvetherapy services (97124 and 97140) to be provided by a licensed acupuncturist.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90791) provided on
January 30, 2019.
You asked the Plan to pay for a psychiatric diagnostic evaluation. You say that you did not receive the needed
information to file this claim timely. The Plan denied your request. The Plan says this claim was filed more
than a year after the service was provided.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for a psychiatric diagnostic evaluation was not filed until September 1, 2020.
This means that more than one calendar year from the date of service had passed before a claim was filed.
Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90791)
provided on January 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET brain scan (78608).
You asked the Plan to pre-approve a PET brain scan (78608). You say that the requested PET brain scan
(78608) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria
for the requested PET brain scan (78608).
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 a PET brain scan (78608). Our reviewer
says that the enrollee does not meet criteria for the requested PET brain scan (78608). Our physician reviewer
found in this case the notes/records provided suggest that the member has Alzheimer's Disease. The impression
of the treating provider and the neuropsychological testing all point to AD as the member's diagnosis. The
requested study would therefore not be used to differentiate between AD and FTD in a patient who meets
diagnostic criteria for both syndromes--as she does not meet criteria for FTD. In as much this request does not
meet Medicare criteria for coverage.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a PET brain scan (78608) have not been met. Therefore, we decided that the
Plan does not have to pre-approve a PET brain scan (78608).
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found long term
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide
clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing
care needs include oxygen supplementation, nebulizer treatments, intravenous steroids, laboratory studies, and
therapy services.
The documentation does not support that the enrollee in this case requires services at the LTACH that are not
available at the acute care hospital where he is currently receiving care. There are no required medical services
identified that are available at the LTACH, that are not available at the current health care setting being offered
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee at this time.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora debridement (11056, 11720, 11721) performed July 20, 2020.You asked the Plan to waive the copayment forthe debridement. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct cost-sharing was 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 $200 copayment for Outpatient Surgery. You have been asked to pay a $200 copayment for the debridement. The debridement 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 waive the copayment fora debridement (11056, 11720, 11721) performed July 20, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay foran ambulance transport (A0425, A0429) provided August 26, 2020.You asked the Plan to pay forthe ambulance transport. You say that the transport was medically necessary.The Plan denied your request. The Plan says the transport to a clinic was not emergent and did not require an ambulance. The enrollee could have been transported by other means.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the ambulance transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found in this case a prudent layperson would not believe that immediate medical attention was required, or that the enrollee's conditioned warranted the equipment or personnel an ambulance provides.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 ambulance transport have not been met.Therefore, we decided that the Plan does not have to pay foran ambulance transport (A0425, A0429) provided August 26, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee can safely receive the services needed 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 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. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for lumbar spine surgery. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Whilethe 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to waive or reducethe $185 copayment ($150 for a PET scan and $35 for basic imaging) provided on December 20, 2019.You asked the Plan to waive or reducethis cost share. You say that you do not believe these copayments are correct.The Plan denied your request. The Plan says each copayment was charged based on the imaging service provided and the Plan contract agreement. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract criteria.The Plan is correct in this case. 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 states there is a copayment or coinsurance for each type of imaging service rendered. You have been asked to pay the correct amount based on the imaging services provided your contract with the Plan. This cost sharing is acontractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive or reducethe $185 copayment ($150 for a PET scan and $35 for basic imaging) provided on December 20, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forthe dental services provided on August 3, 2020.You asked the Plan to pay forthe dental services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says that you have reached your annual plan maximum of $750 for dental services and you are responsible for the remaining amount for these services.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has provided no claims for review to show that the enrollee indeed met the maximum amount of $750 for dental services. The only claim received says that the enrollee had only used $159 of the plan maximum for dental services.Therefore, we decided that the Plan has to pay forthe dental services provided on August 3, 2020.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 toopen the case again, we will send you a letter
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Atorvastatin tablets.
You asked the Plan to pre-approve Atorvastatin tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Atorvastatin tablets are not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Atorvastatin tablets.
Benefits for Atorvastatin tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on August 12, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that in the case where the beneficiary was pronounced dead after the ambulance is called but before the ambulance arrives at the scene: Payment may be made for a BLS service if a ground vehicle is dispatched or at the fixed wing or rotary wing base rate, as applicable, if an air ambulance is dispatched. Providers report the A0428 (BLS) HCPCS code. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services (A0429-QL) have not been met. Specifically, code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Medicare requires the reporting of A0428 for services provided under these circumstances.  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 forthe ambulance services provided on August 12, 2020