Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services of home health/hospice aide (G0156 x48) and direct skilled nursing services of a registered nurse (RN) (G0299 x28).
You asked the Plan to pre-approve the services of home health/hospice aide and direct skilled nursing services of a RN. The Plan denied your request. The Plan says the records show you are able to walk, and move around in your home. The Plan also says that the records do not indicate that you are homebound.
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 services of home health/hospice aide and direct skilled nursing services of a RN. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the documentation does not support that you require skilled nursing services or skilled rehab services to provide treatment that is medically necessary. You do not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. Our reviewer found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Although you appear to be homebound due to your underlying cognitive impairment, there are no skilled needs. Our reviewer also found that you have family that is involved in care and you appear to need cueing or supervision with self-care tasks. Your needs are custodial. 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 services of home health/hospice aide and direct skilled nursing services of a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve services of home health/hospice aide (G0156 x48) and direct skilled nursing services of a registered nurse (RN) (G0299 x28).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the exercise equipment (A9300) purchased February 21,
2021.

You asked the Plan to pay for the exercise equipment. You say that your Plan allows you to purchase exercise
equipment. The Plan denied your request. The Plan says the effective date of the use of the Wellness
Allowance towards exercise equipment was for purchases made between October 1 through December 31,
2020.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers
reimbursement for exercise equipment only when purchased between October 1 and December 31, 2020, and
submitted for reimbursement by March 31, 2021.

The Plan's rules for coverage of exercise equipment have not been met because the purchase was made outside
of the timeframe when the benefit was active. There is no evidence that the Plan extended the temporary well
allowance benefit for exercise equipment into the 2021 plan year. Therefore, we decided that the Plan does not
have to pay for the exercise equipment (A9300) purchased February 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services rendered on February 20, 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 97530 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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 

We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. 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 occupational therapy services rendered on February 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on December 30, 2020.

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you called for this service because of your medical condition, and to avoid going to the hospital for evaluation. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says this service is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on December 30, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on December 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 26, 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 the claim was incorrectly billed.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided on November 27, 2020.
You asked the Plan to pay for self-administered drugs under Medicare Part B. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says self-administered drugs must be submitted to your Part D carrier. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract language.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs provided to you are not among the types which are covered by Medicare Part B. Payment for self-administered drugs must be submitted to your Medicare Part D carrier. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided on November 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
January 22, 2021, through January 23, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically necessary. The Plan denied your request. The Plan says the inpatient stay was consistent with observational level of care.
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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is an 87-year-old male who presented to the emergency department (ED) on January 22, 2021 for evaluation of generalized weakness and dark stools. His medical history was significant for anemia, obstructive asthma, irregular heartbeat, myocardial infarction, orthostatic hypotension, and hypertension. He required an intravenous blood transfusion. His condition stabilized and he was discharged with outpatient follow-up on January 23, 2021. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span 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 not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 22, 2021, through
January 23, 2021.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.

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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic panel testing provided on September 10, 2020. You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic panel testing provided on September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for case presentation, detailed and extensive treatment planning,
(D9450) provided on February 26, 2021.

You asked the Plan to pay for the dental service. You say that you called the plan before your appointment to
make sure that the services would be covered. You say that you were advised they would be. The Plan denied
your request. The Plan says case presentation, detailed and extensive treatment planning, is not listed as a
covered service. The Plan also says that services that are not listed as covered are excluded from coverage.

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. Additionally, the record shows that in the phone call to the Plan, the
representative only advised that the cleaning and exam would be covered. Therefore, we decided that the Plan
does not have to pay for case presentation, detailed and extensive treatment planning, (D9450) provided on
February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office services (CPT code(s): 99215 and 99205) and a general health panel (CPT code 80050) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the medical services. You say that the services are necessary. The Plan denied your request. The Plan says the clinical information submitted does not demonstrate a medical condition that could not be provided by an in-network provider. The Plan states there are contracted providers within your area.
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 the office services (CPT code(s): 99215 and 99205) and a general health panel (CPT code 80050) to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive cardiovascular panel provided on October
19, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the screening
test is not a Medicare benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

We looked at the file and the rules. In this case, there are insufficient medical records to show the results of the
testing would be used in the management of a specific medical problem. The test at issue in this appeal was
requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.
Therefore, we decided that the Plan does not have to pay for the comprehensive cardiovascular panel provided
on October 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for infusion of hydration for the first hour (96360) and for each additional hour (96361), provided on December 22, 2020.

You asked the Plan to waive the coinsurance for infusion of hydration. You say that the coinsurance should be waived because you were never made aware of the charge. The Plan denied your request. The Plan says the cost share 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 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay a 20% coinsurance for infusion of hydration. This service falls within the Medicare Part B prescription drugs 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 infusion of hydration for the first hour (96360) and for each additional hour (96361), provided on December 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for three (3) outpatient hospital visits to apply
an Unna boot (29580, G0463) provided on February 13, 2020, to February 27, 2020.
You asked the Plan to waive the copayment for outpatient hospital visits. You say that you disagree with the
charges. The Plan denied your request. The Plan says the copayment you are being charged is 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 a $250
copayment for each outpatient hospital service.
You have been asked to pay a $250 copayment for each outpatient hospital visit.
For your visit on February 13, 2020, the Medicare Allowed Amount for the service at issue is $135.83. This is
lower than your required copayment responsibility of $250 per visit.
For your visit on February 20, 2020, the Medicare Allowed Amount for the service at issue is $135.83. This is
lower than your required copayment responsibility of $250 per visit.
For your visit on February 27, 2020, you were assessed a $0 copayment for your outpatient hospital visit.
The total cost sharing for the three dates of outpatient hospital services is $271.66 ($135.83 + $135.83 =
$271.66).
The EOC confirms $250 per visit is the required copayment for these services. 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 three (3) outpatient hospital visits to apply an Unna boot (29580, G0463) provided
on February 13, 2020, to February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833), provided on January 5, 2021.
You asked the Plan to pay for the knee orthosis. You say that the item is medically necessary. The Plan denied your request. The Plan says documentation submitted did not include Proof of Delivery or a Delivery Ticket to indicate the specific supplies.
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 a valid proof of delivery for the supplies provided in this case. Medicare requires suppliers to maintain proof of delivery documentation in their files. All services that do not have appropriate proof of delivery will be denied. You have not submitted any proof of delivery documentation. 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 knee orthosis (L1833), provided on January 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for you. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 that the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no
documented need for an intensive rehabilitation program. There is not a reasonable expectation that you 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 IRF admission and services.