Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on February 13, 2020.
You asked the Plan to pay for the consultation (D9310). You say that the Plan sent you to this approved dentist. You say that you were informed a referral was not required. The Plan denied your request. The Plan says the service 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 the consultation (D9310) provided on February 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from August 16, 2019 through August 29, 2019.
You asked the Plan to waive the copayment for the inpatient hospital services. The Plan denied your request. The Plan says that the claim processed 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 $325 copayment per day, days 1 to 5 of Inpatient hospital care. You have been asked to pay a $1,625 copayment for the inpatient hospital services. The inpatient hospital services fall within the days 1 to 5 of Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from August 16, 2019 through August 29, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a portable oxygen concentrator to be provided by an out of network (OON) provider. You asked the Plan to pre-approve the OON oxygen concentrator. You say that the requested provider carries a six liter option while the network provider only carries five liters. You state that you need six liters to meet your needs. The Plan denied your request. The Plan says that this item is available from a network provider so there is no need to provide it out of network. 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. Based on the documentation provided in the case file, Maximus is not able to determine the type of portable oxygen concentrator that is being requested in this case or how it compares to that which is available from the network provider. The appeal letter alleges that the network provider does not have a device which has the required number of liters of oxygen. We requested more information from the plan regarding the specifications of the requested concentrator and the specifications of both the current oxygen equipment and the comparable options available in-network. The Plan merely re-submitted similar documents like those that were in the original case file with no direct responses to the information being requested. Due to not providing this information, the Plan has failed to prove that you have access to the necessary equipment from the network provider. As such, we find that the denial of the out of network provider is not supported. Therefore, we decided that the Plan has to pre-approve a portable oxygen concentrator to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a chest x-ray (71046) and a Computed Tomography (CT) scan of the brain (70450) provided February 10, 2020.
You asked the Plan to waive the copayments for the x-ray and CT scan. You say that the copayments 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 $50 copayment for X-rays and a $160 copayment for Diagnostic Radiology. You have been asked to pay the Medicare allowable amounts of $26.99 for an X-ray and a $95.52 copayment for the CT scan. The allowable amounts were less than the copayment amounts noted in the Evidence of Coverage for each 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 copayments for a chest x-ray (71046) and a Computed Tomography (CT) scan of the brain (70450) provided February 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite and retreatment of previous root canal therapy provided on October 21, 2019.
You asked the Plan to pay for the resin-based composite and retreatment of previous root canal therapy. You say that an in-network dentist sent you for root canal treatment. You say that the issue should be resolved. The Plan denied your request. The Plan says out-of-network dental services are not covered benefits.
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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based composite and retreatment of previous root canal therapy provided on October 21, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IVIG infusions to be administered at home.
You asked the Plan to pre-approve IVIG infusions to be administered at home. You say that you are at a high risk for COVID-19. The Plan denied your request. The Plan says you can safely receive this service in the clinic.
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be 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 IVIG infusions to be administered at home. Our reviewer says that the submitted medical records do not show that you are homebound. Our physician reviewer found there is no evidence that leaving the home is a significant and taxing effort for you. You receive IVIG skilled nursing infusions but have no other skilled nursing need such as complex wound care. There were concerns by the physician about the safety of home IVIG infusions should you have a reaction. There is no evidence that there is a normal inability to leave the home. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IVIG infusions to be administered at home have not been met. Therefore, we decided that the Plan does not have to pre-approve IVIG infusions to be administered at home.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 15, 2020. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the medical services provided to the enrollee by an out-of-network provider on January 15, 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 LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs are being met in the current setting. The LTACH will not provide additional services.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the 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. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (CPT 99152) provided to the enrollee on January 20, 2020. You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 99152 (1 Unit) remains not supported.
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 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older." 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found in this case, the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; therefore, the billed service cannot be verified. Of note, an independent trained observer is someone other than the physician performing the 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (CPT 99152) provided to the enrollee on January 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional therapy visits.
You asked the Plan to pre-approve additional therapy visits. You say that plateauing is not a valid reason to discontinue therapy. You say that more treatment is needed to prevent further deterioration. The Plan denied your request. The Plan says additional physical therapy is not 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 physical therapy. 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 the enrollee has had extensive therapy and was trained in a home exercise program. Our physician reviewer also found that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve additional therapy visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's needs are custodial in nature.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9374) provided on July 5, 2019
You asked the Plan to pay for home infusion therapy. You say that this should be paid. The Plan denied your request. The Plan says this code is not valid for Medicare.
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 S9374 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 (S9374) provided on July 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 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 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 you remain non-ambulatory with profound weakness. You require total assistance for transfers and activities of daily living. The documentation does not support that you require an intensive rehabilitation therapy program. The documentation supports that your care needs can be met 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on February 13, 2020.
You asked the Plan to pay for the presumptive and definitive drug testing. You say that this was medically necessary testing The Plan denied your request. The Plan says there is no evidence in the claims history that this provider is actively treating the enrollee for a specific medical condition. The provider did not submit records showing that this testing was ordered by a physician involved in the enrollee's care.
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. The Plan states that the claims history does not indicate any established relationship. Without a record showing that this provider is treating the enrollee, which was requested by the Plan, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the hearing services rendered on January 27, 2020.
You asked the Plan to waive the deductible for these services. You say that you didn't think it mattered if you were referred to an in- or out-of-network provider. The Plan denied your request. The Plan says the deductible was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $1,000 yearly deductible for your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the hearing services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,000 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on January 27, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the hearing services rendered on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the outpatient hospital clinic visit, the foot surgery, and the specialist office visits provided from January 3, 2020 to January 31, 2020.
You asked the Plan to waive the cost share for the outpatient hospital clinic, the foot surgery, and the specialist office visits. You say that you need the hospital and the doctor's claims paid. The Plan denied your request. The Plan says you have to been charged the correct cost sharing amount
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible that applies towards an in-network outpatient clinic visit and in-network outpatient surgeries and a $35 copayment for in-network physician specialist services. The outpatient clinic visit and the foot surgery you asked the Plan to waive the cost share for falls within the "Outpatient hospital services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that applies to an in-network outpatient clinic and an in-network outpatient surgery and a $35 copayment in-network physician specialist services. This cost sharing is a contractual obligation that had not been met at the time the outpatient hospital clinic, the foot surgery, and the specialist office visits was received on January 1, 2020 to January 31, 2020. Therefore, we decided that the Plan does not have to waive the cost share for the outpatient hospital clinic visit, the foot surgery, and the specialist office visits provided from January 3, 2020 to January 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital services provided from February 3, 2020 through February 6, 2020 and the emergency room visit on February 10, 2020.
You asked the Plan to waive the copayments for the inpatient hospital services and the emergency room visit. You say that you should not be responsible for these costs. The Plan denied your request. The Plan says that claim paid 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 $90 copayment for emergency care and a $360 copayment per day, days 1 to 5 of inpatient hospital care. You have been asked to pay a $90 copayment for the emergency room visit and a $1,080 copayment for the inpatient hospital services. The inpatient hospital services fall within the days 1 to 5 of inpatient hospital care and the emergency room visit falls within the emergency 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 copayments for the inpatient hospital services provided from February 3, 2020 through February 6, 2020 and the emergency room visit on February 10, 2020.