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

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on November 5, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 services provided to the enrollee by an out-of-network provider on November 5, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided from February 6, 2019, to
September 29, 2019.

You asked the Plan to pay for psychotherapy. You say that you should not have to repay the recovery of the
payments issued to you. The Plan denied your request. The Plan says this service is denied because this
provider type is not eligible in the Medicare program therefore the amount sent to you was not correct.

The Plan must follow Medicare rules. Medicare rules say that Original Medicare does not allow all
professionals to directly submit charges for the services that they provide.

We find that the services were provided by a Licensed Marriage and Family Therapist (LMFT). This type of
provider is not eligible for payment. Based on this information, we decided that Medicare rules for coverage of
psychotherapy have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy
provided from February 6, 2019, to September 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewings -
four radiographic images (D0274) provided January 4, 2021.

You asked the Plan to pay for the comprehensive oral evaluation and bitewing x-rays. You say that someone at
the provider's office stated the services would be covered by your insurance. The Plan denied your request. The
Plan says you have met frequency limits for both services and therefore the services at issue are not covered.

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. The Plan covers the
comprehensive oral evaluation and bitewing x-rays when they are provided according to the Plan's frequency
limits.

We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral
evaluation and full mouth x-rays were already provided. Based on this information, we decided
that the Plan's rules for coverage of the comprehensive oral evaluation and bitewing x-rays have not been met.
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and
bitewings - four radiographic images (D0274) provided January 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for six additional physical therapy visits for the enrollee.

You asked the Plan to provide coverage for additional therapy services. You say that additional therapy is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for 6 additional physical therapy (PT) visits. Maximus determined that the plan did not make reasonable and diligent efforts to gather and forward information regarding their decision to deny the request. The Plan stated that the services are not medically necessary; however, no medical records were received for review. Without medical records, a determination based on medical necessity could not be supported. Therefore, it was decided that the Plan had to pre-approve six additional physical therapy (PT) visits.

The Plan has requested a reopen and provided the required medical records. The records show the enrollee is a 73-year-old woman who fell injuring her right hip. The enrollee spent 5 weeks in a transitional care unit, and 6 weeks in a skilled nursing facility. The enrollee received physical therapy (PT) in both facilities. The enrollee was discharged home and had home care PT. There is documentation that the enrollee was admitted to a transitional care hospital with respiratory failure. A tracheostomy tube was placed. The case file contains an Initial Evaluation rehabilitation note. The enrollee's listed diagnoses were Unsteadiness on feet, Other symptoms and signs involving cognitive functions and awareness, Muscle weakness (generalized), and Unilateral primary osteoarthritis, right hip. In terms of gait, it is noted that the enrollee had marked antalgia even with a four wheeled walker. The enrollee could not extend her right hip/knee, and a short stride was noted. "Minimal duration tolerated standing." The enrollee demonstrated fair understanding secondary to some memory issues. It was determined that the enrollee would benefit from skilled PT over two to three months to improve tolerance to movement, gait, strength, and reinforce better functionality.

Based on the medical records provided, the documentation supports that a reduced frequency of PT services was medically reasonable and necessary for the enrollee in this case. Medicare criteria for additional visits were not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional therapy services have not been met. Therefore, we decided that the Plan does not have to provide coverage for six additional physical therapy visits for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to make additional payment for the crown (D2740) and core buildup, including any pins when required (D2950) provided on November 3, 2020.
You asked the Plan to pay for the crown and core buildup. You say that you believe these services should be covered. The Plan denied your request. The Plan says that the only service that was not covered by the second dental plan was the preventive procedure, and the dentist wrote this off. The Plan also says that the crown and core buildup have a 50% copayment each, and you are responsible for $494.50.
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, you must pay a 50% coinsurance for the crown and core buildup. Therefore, we decided that the Plan does not have to make additional payment for the crown (D2740) and core buildup, including any pins when required (D2950) provided on November 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the total electric hospital bed (E0297) provided November
14, 2020.

You asked the Plan to pay for the total electric hospital bed. You say that Medicare does allow this to be billed
monthly. It allows $108.63 per monthly rental. Please review the attached fee schedule printed off the LCD.
The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to pay for the total electric hospital
bed (E0297) provided November 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam and eyewear provided on November 17, 2020.

You asked the Plan to pay for the eye exam and eyewear. The Plan denied your request. The Plan says you
must use a Plan provider for these services.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. 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.

We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the
Plan. 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 an eye exam and eyewear
provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on December 31, 2020.

You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 requested provider in this case is not a network provider with the Plan. 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 nurse practitioner services provided on December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on
November 3, 2020.
You asked the Plan to pay for the first intraoral periapical x-ray. You say that you would like to appeal this
service. The Plan denied your request. The Plan says this service is not a covered benefit under your dental
plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first
intraoral periapical x-ray (D0220) provided on November 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical and occupational therapy to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve physical and occupational therapy. You say that this physician provides services in your assisted living facility. The Plan denied your request. The Plan says there are in-network providers available for these services.

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 physical and occupational therapy to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on a tendon sheath incision (26055-AS) provided on October 21, 2020.
You asked the Plan to pay for surgical assistant services. You say that an assistant surgeon was required for this service. The Plan denied your request. The Plan says assistant surgeons are not permitted for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 26055. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services on a tendon sheath incision (26055-AS) provided on October 21, 2020.
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 needs can be met at an alternate 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 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 osteomyelitis of the sternum. Medical problems are stable. 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for interrogation device evaluation (93281) provided November 30, 2020 to December 10, 2020.

You asked the Plan to waive the copayment for the diagnostic service. You say that this visit was a follow up from pacemaker surgery. Device adjustment obviously was part of the follow up and should not be charged. The Plan denied your request. The Plan says pacemaker device evaluations are considered diagnostic tests and therefore not included in the 90-day global period associated with the surgery.

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 $50 copayment for all other in network diagnostic tests.

You have been asked to pay $50 copayment for the diagnostic service. The diagnostic service falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 interrogation device evaluation (93281) provided November 30, 2020 to December 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second epidural injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is no role for a series of injections.
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 the injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the local coverage determination indicates that the response to an initial injection is to be assessed to determine if a subsequent injection is needed. In this case, the request is for a series of injections. The requested service cannot be recommended. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a second epidural injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the oxygen concentrator provided on
December 1, 2020.

You asked the Plan to waive the copayment for the oxygen concentrator. You say that you were told the
oxygen equipment would be covered 100%. The Plan denied your request. The Plan says you were charged this
coinsurance 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 20%
coinsurance for Durable Medical Equipment.

You have been asked to pay 20% coinsurance for the oxygen concentrator. the oxygen concentrator falls within
the Durable Medical Equipment 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 oxygen concentrator provided on December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acupuncture services

You asked the Plan to pre-approve the acupuncture services. You say that you have seen your doctor for several years regarding severe pain in your feet and throughout your body. You would like to try this treatment as your doctors agree that acupuncture could be helpful for the relief of your pain. The Plan denied your request. The Plan says the enrollee does not meet the criteria as the enrollee does not have a diagnosis of chronic low back pain. Peripheral neuropathy and bilateral foot pain are not covered.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the records do not show that the enrollee has a diagnosis of chronic low back pain. The request was initiated for treatment of pain in both feet and peripheral neuropathy, which is not covered. Therefore, we decided that the Plan does not have to pre-approve the acupuncture services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the acute inpatient hospital care for the enrollee.

You asked the Plan to provide coverage for acute inpatient hospital care. You say that inpatient care was medically necessary at the time it was requested. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an inpatient admission for the dates January 21, 2021 through January 25, 2021. The Maximus Physician Reviewer determined that the documentation supported that the criteria for inpatient payment were met in this case. The reviewer found that the record showed that, at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. The Plan argues that the enrollee did not require acute hospitalization and could have received services outside of the acute care setting.

The medical records show the enrollee is a 79-year-old woman with a diagnosis of stage IV metastatic pancreatic adenocarcinoma, who presented to the hospital following a fall. The enrollee had been progressively declining and could not perform activities of daily living on her own. The enrollee expressed a desire for comfort measure only. The enrollee was in no acute distress and had normal vital signs. It was determined that the enrollee was unable to care for herself at home. Hospice and palliative care were consulted. The anticipated duration of hospitalization was unclear, pending evaluation by hospice, as well as by social work for probable placement beyond this hospitalization. The enrollee's condition was stable, with a terminal long-term prognosis. Comfort care measures only were to be implemented.

Our Medical Director has concluded that the Plan is correct in this case. The documentation does not support that the enrollee in this case required services in an acute care hospital spanning two midnights. 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 does not have to provide coverage for the acute inpatient hospital care for the enrollee.