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

We decided that the Plan has to waive the copayment forthe cataract surgery provided on September 3, 2019.You asked the Plan to waive the copayment forthe cataract surgery. You submitted your bill for review.The Plan denied your request. The Plan says that you have 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan does not say in clear and accurate terms how much you should expect to pay for outpatient surgery. You pay 0% or 20% coinsurance for each Medicare-covered visit to an ambulatory surgical center (including epidural injections). We looked at your contract with the Plan. The contract says enrollees must pay 0%or 20% coinsurance for the cataract surgery. The Explanation of Benefits shows you are responsible for a $0/ $219.27 coinsurance amount.The Plancontract does not explain which amount you should be expected to pay. Therefore, we cannot clearly decide which amountyou would be expected to pay. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information.Therefore, we decided that the Plan has to waive the copayment forthe cataract surgery provided on September 3, 2019.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: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, additional intraoral periapical x-ray, and oral hygiene instructions provided on February 24, 2020.
You asked the Plan to pay for these dental services. You say that these dental services were medically necessary. The Plan denied your request. The Plan says the benefits for the services provided were previously exhausted. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information showing when the previous benefits were rendered.
The Plan is correct in this case. Medicare does not cover dental services. 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 services were not available at the time of service. The Plan covers two oral exams per calendar year and 4 periapical x-rays in a 12-month period. The Plan previously paid for exams provided on February 16, 2020 and February 18, 2020. The Plan previously benefited 2 periapical x-rays on February 18, 2020. The claim for February 24, 2020 included 3 periapical x-rays. The first 2 periapical x-rays were approved on February 24, 2020, totaling 4 in the 12-month period. Therefore, you did not have coverage available for the additional exam or x-ray on February 24, 2020. The Plan provided the Explanation of Benefits statements showing the benefits were previously paid for these services the frequency limitation had been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, additional intraoral periapical x-ray, and oral hygiene instructions provided on February 24, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan does not have to waive or reducethe cost share for a diagnostic ultrasound ($66.29) and a vascular study ($5) provided on August 4, 2020.You asked the Plan to reducethis cost share. You say that you do not believe this cost share is correct.The Plan denied your request. The Plan says this cost share was charged based on the services 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 benefits. The Plan says that ultrasounds are diagnostic radiology services. The claim submitted by the provider resulted in a $66.29 copayment for this ultrasoundwhich is less than the normal $100 copayment. The Plan states the $5 copayment for additional vascular services was also correct.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 with the Plan clearly says that you must pay $100 copayment for outpatient radiology and $5 copayment for vascular studies. In this case you were asked to pay less than your normal copayment for the ultrasound service and the appropriate amount for the vascular service. 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 reducethe cost share for a diagnostic ultrasound ($66.29) and a vascular study ($5) provided on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the sacroiliac joint injection. The Plan denied your request. The Plan says a 
sacroiliac joint injection is available within the enrollee's health plan network. It was determined there is no 
reason to obtain services requested from an out of network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
sacroiliac joint injection to be provided by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for a PET scan with an out-of-network 
provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral for a PET scan with an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental braces. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit under your dental policy. 
 
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 item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental braces.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that all services that would be provided in the LTACH are being 
provided already in the current acute care setting already approved. 
 
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. The enrollee 
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 she is currently receiving care. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 51 additional 1-hour skilled nursing visits. 
 
You asked the Plan to pre-approve 51 additional 1-hour skilled nursing visits. You say that the necessity of 
home health services has been identified by the caring physician. You say that the enrollee requires nebulizer 
treatments every 6 hours. You say that the enrollee is home bound on a hospital bed due to range of motion 
impairment and hip replacement. You say that the enrollee had occasional physical therapy and occupational 
therapy. You also say that the enrollee requires home health skilled nursing services as they are necessary for 
the enrollee's safety, wellbeing and decreased hospitalizations. The Plan denied your request. The Plan says the 
provided documentation does not show a medical need for a skilled nurse. The Plan also says there are no 
signed orders or any documentation from your doctor that a face to face visit has been completed. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 51 additional 1-hour skilled nursing 
visits. Our reviewer says that the 51 additional 1-hour skilled nursing visits are not medically necessary. Our 
physician reviewer found the provided documentation does not show that skilled nursing services are required 
to effectively provide treatment, care, and/or services in order to improve the patient's condition, or to 
establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The 
reviewer found that the documentation does not reveal complex wound care, IV antibiotics, new enteral 
feedings or evidence of an ongoing SN need that requires the remaining 51 additional 1 hours visits. Therefore, 
the reviewer found that the 51 additional 1-hour skilled nursing visits are not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 51 additional 1-hour skilled nursing visits. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 51 additional 1-hour skilled nursing visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga. 
 
You asked the Plan to pre-approve Farxiga. The Plan denied your request. The Plan says this drug is not 
covered for the enrollee's condition by Medicare Part B. 
 
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 Farxiga.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre sensor. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee cannot afford a Dexcom 
device. The Plan denied your request. The Plan says there has been no trial of a preferred device. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may limit the DME to only those preferred 
brands and manufacturers 
 
We looked at the file and Medicare rules. The medical records provided do not indicate the enrollee is unable 
to use a preferred device. 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 pre-approve a Freestyle Libre sensor.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
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 your care needs can be provided in a lower level of care setting 
 
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 your 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.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that you are unsteady on your feet, and need walking 
assistance. The Plan denied your request. The Plan says there are no daily skilled nursing or therapy needs. 
 
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 physician reviewer 
found that from a nursing perspective, you had stable vital signs, your lungs were clear, and you were treated 
for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, you were 
at a standby assist to contact guard assist level with functional mobility. You required varying assist with 
activities of daily living. Although there are identifiable skilled therapy service needs, you do not require 
skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service 
criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup. 
 
You asked the Plan to pre-approve the backup. You say that you live in an area with no energy stability. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
A battery backup is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a 
battery backup.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting. 
 
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 for surgical treatment of a C6 fracture after a fall. 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 this 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the services you 
require can safely be received in the current SNF. 
 
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 physician reviewer 
found that from a nursing perspective, you received oral medications and had stable vital signs. There are no 
identifiable skilled nursing service needs. Regarding rehab services, you were at a supervision to contact guard 
assist level with functional mobility. You required varying assist with activities of daily living. There are no 
identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily 
basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on 
September 29, 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 a modifier was not billed on the claim to represent the services as separate/distinct. 
 
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 71045 is "radiologic examination, chest; single view." 
 
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 
services at issue in this case were not supported by the medical records. Our coding reviewer found CPT 71045 
26 was billed by the same physician/practice on the same day as CPT code 32555 and is considered bundled to 
this service (32555).  However, a modifier is allowed to unbundle the service, providing the medical 
documentation supports unbundling the service. When the medical documentation supports unbundling 
Procedure-to-Procedure code pairs, an appropriate modifier must be submitted with the code at the time of 
billing in order for the code to be considered for reimbursement.  In this case, the provider did not append a 
modifier to unbundle service 71045 from service 32555, therefore, it cannot be considered for reimbursement. 
 
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 radiology services (CPT 71045) provided to the enrollee on September 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin 
with at least three daily injections, and requires frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.