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

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF 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 rulesto 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 enrolleerequired moderate assistance with transfers. The enrollee required minimal assistance with walking 16 feet with a rolling walker. The enrollee's medical status does not require intensive physician or nursing supervision in an IRF currently. The enrollee'srenal function in at baseline. The enrollee's platelets are increasing and improved off Zyvox. While the enrollee may benefit from further physical therapy and occupational therapy, the documentation does not indicate that the enrollee can tolerate this therapy on an intensive level in an IRF given multiple episodes of significant fatigue in therapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from October 27, 2019 to November 4, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 daysper benefit period is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from July 12, 2019 to November 28, 2019. ThePlan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from October 27, 2019 to November 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp (J0882). You asked the Plan to pre-approve the Aranesp. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this drug will be bundled into payment to the dialysis agency. The Plan must follow Medicare rules. Medicare rules say that Erythropoiesis stimulating agents (ESAs)  when furnished to Medicare ESRD patients are always considered to be renal dialysis services and included in the ESRD PPS. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Aranesp have not been met. Specifically, the requested drug is considered to be a renal dialysis service and included in the ESRD PPS. Separate payment for this drug cannot be pre-approved by the Plan. Therefore, we decided that the Plan does not have to pre-approve Aranesp (J0882).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile radiology services (73502, Q0092, R0070) provided on August 7, 2019.
You asked the Plan to pay for the mobile radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not preauthorized or emergent. There were 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 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 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 mobile radiology services (73502, Q0092, R0070) provided on August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemedical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the OON services. The Plan denied your request. The Plan says the requested service is available in-network.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 OON services.Therefore, we decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a PSA screening (G0103) provided on December 9, 2019.
You asked the Plan to pay for the PSA screening. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says you were provided a second PSA test within the 2019 calendar year which is not covered under the terms of your Evidence of Coverage.
The Plan must follow Medicare rules. Medicare rules say that screening prostate specific antigen tests are covered at a frequency of once every 12 months for men who have attained age 50. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PSA screening have not been met. Specifically, the record indicates that this is the second PSA test you have received in 2019. This exceeds the benefit limits. Therefore, we decided that the Plan does not have to pay for a PSA screening (G0103) provided on December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered to you on January 6, 2020.You asked the Plan to waive the copayment for these services. You say that you disagree with the charges.The Plan denied your request. The Plan says the copayment was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for specialist visits. The file shows that you received specialist services on January 6, 2020. The services are considered a specialist visit and not an eye exam because they were a pre-surgical consultation for the diagnosis of endothelial corneal dystrophy. You have been asked to pay a $50 copayment for these services. These services fall within the specialist 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 copayment for the specialist services rendered to you on January 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea standard wheelchair.You asked the Plan to pre-approvea standard wheelchair. You say that you need a standard wheelchair because you have fallen backwards and hit your head.The Plan denied your request. The Plan says there is a lack of medical necessity.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no documentation that you meet the criteria for a standard wheelchair. Based on this information, we decided that Medicare rules for coverage of a standard wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approvea standard wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 11042 provided on August 24, 2018.
You asked the Plan to pay for CPT code 11042. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The file contains medical records submitted by the provider without a patient name on the records. In order to verify if Medicare criteria have been met, the records need to include the enrollee's name. Therefore, we decided that the Plan does not have to pay for CPT code 11042 provided on August 24, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair (E0240).You asked the Plan to pre-approve a shower chair. You say that you are requesting a reconsideration of the Plan's denial as a shower chair is medically necessary.The Plan denied your request. The Plan says that a shower chair is not a covered benefit under your contractual policy.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate for you in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemedical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the OON services. You say that failure to undergo therapy would result in inadequate treatment.The Plan denied your request. The Plan says network services are 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 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 medical services to be 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 a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on October 17, 2019. You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on October 17, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from December 1, 2018 through December 4, 2018.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. 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. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found due to the initial evidence suggestive of likely sepsis, admission was appropriate which would have required at least a two-midnight stay in the hospital for appropriate monitoring and treatment sufficient to observe stability. Therefore, based on the clinical presentation prior to admission, the criteria had been met for admission.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 forthe acute inpatient hospital care provided from December 1, 2018 through December 4, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power wheelchair vehicle lift.You asked the Plan to pre-approvea power wheelchair vehicle lift. You say that the usefulness of your chair is nullified without an effective and convenient way to transport it.The Plan denied your request. The Plan says Medicare considers this item a convenience item and not necessary for the treatment of an illness or injury.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that Medicare will pay for durable medical equipment that is needed for use in the home.   The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea power wheelchair vehicle lift.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on November 7, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a drug test. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 a drug test provided on November 7, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of an impacted tooth (D7230).You asked the Plan to pre-approve the removal of an impacted tooth. You say that you need to have this tooth removed. You say that it is causing you pain. You also say that it is affecting your health.The Plan denied your request. The Plan says the removal of an impacted tooth is not listed as a covered service.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 removal of an impacted tooth is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve the removal of an impacted tooth (D7230).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on October 29, 2019, and October 30, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the submission of a device-dependent procedure also requires that a device be submitted on the same claim/day.
The Plan must follow Medicare rules. Medicare rules say that procedure codes that require the use of devices must be reported with the applicable HCPCS codes and charges for all devices that are used to perform the procedures where such codes exist. We looked at the file and Medicare rules. The claim in question was not billed with an appropriate device code which was used to perform the procedure in question. In this case, it appears that the appropriate code would be C1776. 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 the services provided on October 29, 2019, and October 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea total disc arthroplasty.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the criteria for lumbar disc replacement are not met. The records show that you have degeneration at two levels of the spine on magnetic resonance imaging (MRI). You also have narrowing of the spine (stenosis). Total disc replacement isconsidered experimental in nature for multilevel lumbar degeneration and is therefore not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea total disc arthroplasty. The Plan references Local Coverage Article (LCA) A57642 in their determination; however, this LCA states that the procedure is not medically necessary for enrollees under the age of 60 and does not apply to the enrollee. This LCA was not used in the MAXIMUS determination.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D2952 and D4249).You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis 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 Plandoes not haveto pre-approvedental services (D2952 and D4249).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care, 15 minutes (99308-25) provided on October 16, 2019 by the appealing provider.
You asked the Plan to pay for subsequent nursing facility care, 15 minutes. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says based on the documentation provided, the claim was processed correctly.
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 99308-25 is subsequent nursing facility care, 15 minutes. 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 subsequent nursing facility care, 15 minutes. Our reviewer says that the service is not supported by the medical records. Our coding reviewer found the medical records submitted do not indicate the physician provided additional care management beyond the wound care services he performed following his assessment. Wound care provided was CPT codes 11042, 11043, 11045 and 11046 of which CPT 99308 would be included in one or more of these services. In this case, it would not be appropriate to bill 99308 with a 25 modifier. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of subsequent nursing facility care, 15 minutes have not been met. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care, 15 minutes (99308-25) provided on October 16, 2019 by the appealing provider.