Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary.The Plan denied your request. The Plan says that there is no evidence provided that member's treatment needs could not be met at a less restrictive, outpatient level of care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee in this case. It is not expected this enrollee would improve in a reasonable period of time as he is not showing any dangerousness to self or others, auditory or visual hallucinations and is without aggressive behaviors. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he does not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive metabolic panel blood test and the blood draw provided on March 6, 2020.
You asked the Plan to waive the copayment for the comprehensive metabolic panel blood test and the blood draw. You say that the laboratory work was a part of your annual wellness visit and you should not have a copayment. The Plan denied your request. The Plan says 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 clearly says that you must pay a $15 copayment per visit for all other laboratory tests. You have been asked to pay a total of $15 copayment for the comprehensive metabolic panel blood test and the blood draw. The comprehensive metabolic panel blood test and the blood draw fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows that these laboratory tests are considered outpatient laboratory tests.
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 comprehensive metabolic panel blood test and the blood draw provided on March 6, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied your request. The Plan says that rules for coverage were not met.
The Plan follows Medicare rules. Medicare rules say that CGM's are covered when 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 the CGM. Our reviewer says that coverage criteria has been met. Our physician reviewer found the record shows the enrollee is diabetic and tests his blood glucose 4 times daily and injects Novolog up to 4 times daily. The test results are used to adjust dosage. The CGM is medically 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 the CGM have been met. Therefore, we decided that the Plan has to pre-approve a continuous glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health skilled nursing visits.You asked the Plan to pre-approve the additional visits. You say that this is medically necessary.The Plan denied your request. The Plan says the records do not support the need for additional skilled nursing visits.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 the additional visits. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. Your wound care is not complex, and the documentation does not reveal other ongoing SN needs the require SN beyond what was approved 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 additional visits have not been met.Therefore, we decided that the Plan does not have to pre-approve additional home health skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe removal of a kidney stone (50081) and exchange nephrostomy catheter (50435) provided on March 19, 2020.You asked the Plan to pay forthe kidney stone removal and exchange nephrostomy catheter. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says anatomic modifiers are required whenever they are appropriate.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 codes 50081 and 50435 are not supported in the record. Specifically, the record indicates that these procedures were rendered on the right side of the body. The claim was submitted without appropriate anatomic modifiers to represent the service performed. Based on this information, we decided that Medicare rules for coverage of the kidney stone removal and exchange nephrostomy catheter have not been met.Therefore, we decided that the Plan does not have to pay forthe removal of a kidney stone (50081) and exchange nephrostomy catheter (50435) provided on March 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia injections (J0897).You asked the Plan to pre-approvethe Prolia. You say that the enrollee is unable to take Calcium and Vitamin D or biophosphonates. You also say that due to the risk of reflux and worsening esophagitis, Prolia would be beneficial in managing the enrollee's osteoporosis.The Plan denied your request. The Plan says the Prolia injections are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Prolia.Our reviewer says that Prolia does not meet the Plan's coverage criteria. Our physician reviewer found the enrollee is noted to have osteoporosis based on a recent dual-energy x-ray absorptiometry (DEXA) scan. There is no evidence that the enrollee takes calcium or vitamin D. Our reviewer found that there is no evidence that the enrollee has tried other osteoporosis medications, which were then proven to be ineffective or not tolerated. Our physician reviewer also found that the documentation does not support that the use of Prolia is currently medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia injections (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on March 7, 2020.You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the charges because the provider was rude.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 $50 copayment for urgently needed services. You have been asked to pay a $50 copaymentfor urgently needed services. Urgently needed services fall within the urgently needed services 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 urgently needed services provided on March 7,2020.Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
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 reconsideration because IRF admission is medically necessary. The Plan denied your request. The Plan says the member can safely receive necessary services at a lower level of care.
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 based on the medical records provided the complexity of the member's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not require an intensive inpatient rehabilitation therapy program. There is concern that the member will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 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 forthe drug testing services provided on October 2, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed services cannot beverified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. 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 drug testing services provided on October 2, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on October 22, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe drug testing rendered on October 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for digital breast tomosynthesis (77061) provided on January 2,
2020.
You asked the Plan to pay for the digital breast tomosynthesis. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says CPT code 77061 has a status code
if I which is not valid for Medicare purposes.
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 77061 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code 77061 has a status indicator of I. This means that CPT code 77061 is not valid for Medicare purposes.
Based on this information, we decided that Medicare rules for coverage of the digital breast tomosynthesis have
not been met. Therefore, we decided that the Plan does not have to pay for digital breast tomosynthesis (77061)
provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on February 3,
2020.
You asked the Plan to waive the deductible for the office visit. You say that you should not be responsible for
the deductible amount. The Plan denied your request. The Plan says 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. Your
contract with the Plan says that there is a $198 combined deductible that applies towards in-network office
visits.
The office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services,
including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in
the contract that there is a $198 combined deductible that applies towards in-network office visits. This cost
sharing is a contractual obligation that had not been met at the time the office visit was received on February 3,
2020. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on
February 3, 2020.
Your complaint that you were signed up for the wrong insurance plan is not a valid appeal for medical
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not
permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe pacemaker procedure provided on February 6, 2020.You asked the Plan to waive the coinsurance forthe pacemaker procedure. You say that you only had to pay a $200 copayment last time. You say you could have had this done in the office. The Plan denied your request. The Plan says 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 clearly says that you must pay 20% coinsurance for each outpatient hospital facility visit, including physician or surgical charges. You have been asked to pay $2,360.38 which is 20% of the allowed amount for the pacemaker procedure.The allowed amount is $11,801.90. ($11,801.90 x 20% = $2,360.38). The pacemaker procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical center" benefit category. This means thatyou 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 forthe pacemaker procedure provided by on February 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fornasal endoscopy surgeries provided from January 24, 2020 to February 20, 2020.You asked the Plan to waive the copayment for endoscopies. You say that you thought these visits were all part of the same surgery, so this bill should not exist.The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.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 $300 copayment for each outpatient hospital visit for a nasal endoscopy. There were 3 separate visits, resulting in a total copayment obligation of $900.You have been asked to pay $300 copayment for each endoscopy. Endoscopies fall 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 haveto waive the copayment fornasal endoscopy surgeries provided from January 24, 2020 to February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9328) provided on February 10, 2020 to February 17, 2020.You asked the Plan to pay forhome infusion therapy. You say that the CMS website says this is a valid code.The Plan denied your request. The Plan says this code is not valid for Medicare purposes.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 S9328 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 forhome infusion therapy (S9328) provided on February 10, 2020 to February 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit, laboratory service, and pharmacy charges provided on September 20, 2019.You asked the Plan to pay foroffice visit, lab work, and drugs. You say that you are submitted reimbursement forms with receipts.The Plandenied your request. The Plan says the denial of payment for these services is correct, because it was determined that proof of payment was not received for services.The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover items or services provided outside of the United States, except in the specific circumstances described on the previous page. Medicare rules say that you must furnish to the Plan sufficient information to determine whether payment is due for a claim when requesting reimbursement. The Plan contract has a benefit for worldwide coverage that goes beyond Medicare's benefit, for that reason the Plan's benefits apply to this case. The Plan covers worldwide emergency and urgent care services, including emergency transportation when needed.We looked at the file and Medicare rules. While you did submit receipts detailing the services for which you are requesting reimbursement, you did not submit any medical records to verify the services that you are requesting payment for. Without medical records, we cannot determine whether the services you are requesting payment for were emergent or urgent in nature, and the documentation submitted does not show that Medicare or the Plan's criteria for coverage have been met.Based on this information, we decided that the Plans rules for coverage of office visit, lab work, and drugs have not been met.Therefore, we decided that the Plan does not have to pay foran office visit, laboratory service, and pharmacy charges providedin on September 20, 2019
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can safely be received in another setting, as LTACH does not provide clinical advantage over a non-LTACH acute care hospital.
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 on 7/18/20, the enrollee was breathing better, and was in no distress. Her blood pressure was elevated, and medication adjustments were made. 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. The enrollee is receiving acute hospital care, and acute care services have not been denied. 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 she 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 admission to a long term acute care hospital (LTACH) for the enrollee.