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

We decided that the Plan does not have to waive the copayment for a colonoscopy.

You asked the Plan to waive the copayment for a colonoscopy. You say that you were never told that polyps were removed and feel that the colonoscopy was billed incorrectly. 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 $295 copayment for outpatient surgery, including services provided at an ambulatory surgical center.

The medical records show that you had polyps removed during a colonoscopy. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $295 copayment.

You have been asked to pay a $295 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a colonoscopy.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for for the guided tissue regeneration (D4266) provided on December 9, 2019.

You asked the Plan to pay for the guided tissue regeneration. You say that the policy book does not state that specific teeth are covered for the porcelain crown and guided tissue regeneration. The Plan denied your request. The Plan says that a guided tissue regeneration performed in conjunction with an extraction site is considered a specialized technique. The Plan also says that specialized techniques are not a covered benefit under your dental plan.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. Y

You were referred for the guided tissue regeneration by a contract provider. The file does not show that the Plan provided notice that the guided tissue regeneration would not be covered. The Plan denied the service saying that a guided tissue regeneration performed in conjunction with an extraction site is considered a specialized technique. The EOC does not clearly say that specialized techniques regarding guided tissue regenerations are not covered. You reasonably believed this service would be covered because surgical periodontic procedures are limited to one (1) surgical periodontal treatment per quadrant every 36 months. Under Medicare rules, this means the guided tissue regeneration is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the guided tissue regeneration (D4266) provided on December 9, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered.

You asked the Plan to waive the copayment for these services. You say that you have not paid this amount in
the past. 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 $225
copayment for each Medicare-covered ambulatory surgical center visit for services other than surgical
procedures during a colorectal screening.

Review of the file shows that you received outpatient services at an ambulatory surgical center. You have been 
asked to pay a $225 copayment for these services. These services fall within the Medicare-covered ambulatory 
surgical center visit for services other than surgical procedures during a colorectal screening 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 outpatient surgical 
services rendered.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health services.

You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee's current needs are not skilled in nature.

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.

Continued home health services were requested. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued services. Our physician reviewer found that in this case, the documentation does not support that the enrollee requires additional skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The enrollee does not require skilled nursing or rehab services in order to improve his condition, perform a maintenance program, or prevent deterioration. He received skilled rehab services without meaningful improvement in function and does not require further services. At this time, there is no indication that he has any skilled nursing needs.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services provided on October 30, 2020 by an out of network (OON) provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.

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 for the debridement services provided on October 30, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you are a fall risk with limited mobility. The Plan
denied your request. The Plan says you are unable to tolerate an intensive therapy program.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found
that you have a past medical history of stroke, diabetes, dementia, hypertension and are living at home with
increasing weakness despite home health services. Your medical problems are stable. There are no complex
nursing needs. There is not a reasonable expectation that you will be able to fully participate in and benefit
from the intensive rehabilitation therapy program. While the medical record supports a need for physical and/or
occupational therapy, there is no documented need for intensive rehabilitation 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan
requires the utilization of in-network providers unless the Plan pre-approves out-of-network services in nonemergent
situations. Authorization for out-of-network services 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.

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..
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient hospital services provided by a participating provider.

You asked the Plan to waive the coinsurance for outpatient hospital services. You say that you do not agree with this coinsurance. 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 5% coinsurance for outpatient diagnostic tests/in-network/outpatient hospital visit.

You have been asked to pay a 5% coinsurance of the allowed amount for outpatient hospital services. The allowed amount is $103.44. The total amount you are being asked to pay is $5.17 ($103.44 x 5% = $5.17). Outpatient hospital services fall within the outpatient diagnostic tests/in-network/outpatient hospital visit 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 outpatient hospital services provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an inpatient hospital stay and a specialist visit provided from November 10, 2020, to January 6, 2021.

You asked the Plan to waive the copayments for an inpatient hospital stay and a specialist visit. You say that you had complications after a procedure and feel that you should not have to pay for the follow-up care. 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 $150 copayment for days 1-5 for inpatient hospital care. Your contract with the Plan also clearly says that you must pay a $35 copayment for specialist visits. 

You had an inpatient hospital stay from November 10, 2020, to November 12, 2020. Therefore, you are responsible to pay a $150 copayment for days 1-2 (November 10, 2020, to November 11, 2020). $150 (copayment) x 2 (inpatient days) = $300. 

You had a specialist visit on January 6, 2021. Therefore, you are responsible to pay the $35 copayment. 

The total amount you owe is: $335. 

You have been asked to pay the total copayment amount of $335 for an inpatient hospital stay and a specialist visit. An inpatient hospital stay falls within the inpatient hospital care benefit category. A specialist visit falls within the physician/practitioner services including doctor's office visits 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 an inpatient hospital stay and a specialist visit provided from November 10, 2020, to January 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the leg joint.

You asked the Plan to pre-approve MRI. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this MRI is correct, because there is insufficient evidence indicating failure of reasonable conservative care, an equivocal X-Ray study, or significant objective deficits on examination.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 MRI. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested MRI. Our physician reviewer found there is insufficient documentation of trial and failure of conservative measures, so this MRI has not been shown to be medically reasonable and 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the leg joint.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided the Plan has to pay for inpatient care provided to the enrollee.

You asked the Plan to pay for acute inpatient hospital care. You say that inpatient admission was medically necessary. The Plan denied your request. The Plan says that Medicare criteria for inpatient care were not met. Maximus overturned the Plans denial because medical records were not provided for review. The Plan requested a reopen and provided the required medical records for review.

Our Medical Director looked at the case file, the reopen request and the medical records. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. At issue is coverage for inpatient services. The medical records show the enrollee was a then 81-year-old woman who presented to the hospital with abdominal pain and dark stools for 2 days prior. The enrollee was reportedly incontinent of urine and was unable to get to the bathroom due to the severity of the pain. The enrollee's medical history was notable for hypertension and COPD, and she was anticoagulated for atrial fibrillation. The enrollee was anemic with a hemoglobin of 7 g/dL. The BUN was 28 mg/dL and the creatinine was 0.58 mg/dL. The enrollee's stool was heme positive. The diagnosis was gastrointestinal bleeding. Morphine was administered for pain, and packed red blood cells were transfused.

Based on the medical records provided, our Medical Director has concluded that the documentation supports that it was reasonable for the admitting physician to expect that the enrollee's necessary hospital care would span two midnights, given her age, medical history, and presentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for inpatient care provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound debridement provided by an out-of-network provider.

You asked the Plan to pay for wound debridement. You say that the provider is contracted with the Plan. You say that payment should be considered due to the patient condition and pandemic emergency. The Plan denied your request. The Plan says the plan requires the utilization of in network providers.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for wound debridement provided by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services provided by an out of network (OON) provider.

You asked the Plan to pay for the provided services. You say that the services were incorrectly billed. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available to 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 ultrasound services provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor supplies provided to the enrollee from August 17, 2020 to September 17, 2020.

You asked the Plan to pay for these services. You say that this should be paid for. The Plan denied your request. The Plan says that the records from the provider does not show any indication of a discussion with the patient to switch to Continuous Glucose Monitoring (CGM).

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor supplies provided to the enrollee from August 17, 2020 to September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services rendered on August 8, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99356 is 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 99356 is prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient or observation Evaluation and Management service). 

We find that CPT code 99356 is not supported in the medical record. Specifically, the documentation does not support an hour of prolonged services spent on the enrollee. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the physician services rendered on August 8, 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 enrollee was self-sufficient prior to her fall and required no assistance from a cane, walker, or wheelchair. You say that and IRF would provide the enrollee with a positive environment and proper equipment that would allow her to complete the required therapy. You say that the enrollee has experienced acute inpatient therapy with successful results and believes the skilled nursing rehabilitation would not assist the enrollee to regain her independence. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed 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 in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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 surgery to treat a fracture of the right leg. The enrollee's medical problems are stable. 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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.