Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan does not have to waive or reducethe coinsurance charged for outpatient services provided on March 3, 2020.You asked the Plan to waive or reducethis coinsurance. You say that you do not believe this coinsurance is correct.The Plan denied your request. The Plan says this coinsurance was charged based on the services provided and the Plan contract agreement for outpatient services in an ambulatory center. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract language. The Plan says that you were charged 20% coinsurance for services at an ambulatory surgical center. That coinsurance is allocated to each line of service based on the Medicare billing guidelines and the Plan contract rules for this type of care.The Plan is correct in this case. 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 outpatient services provided in an ambulatory surgical center. This can result in a coinsurance for each service provided along with the facility fee. 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 or reducethe coinsurance charged for outpatient services provided on March 3, 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). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says rehab needs are not complex, and do not require an interdisciplinary approach with 
multiple specialists to oversee rehab 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 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 were admitted for sepsis, urinary tract infection and kidney failure requiring dialysis. Medical conditions 
are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a 
need for physical and occupational therapy, it does not document a 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable x-ray services provided (R0070, Q0092, 71045). 
 
You asked the Plan to pay for the portable x-ray services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says these services were not 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 services at issue in this appeal. The Plan did not pre-approve the service 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 portable x-ray services provided (R0070, Q0092, 71045).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture provided on June 16, 2020 by 
an OON provider. 
 
You asked the Plan to pay for the maxillary partial denture. You say that you need this denture. The Plan 
denied your request. The Plan says this service was received and processed correctly. 
 
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 75% coinsurance for 
the maxillary partial denture received by an OON provider. Therefore, we decided that the Plan does not have 
to pay for the maxillary partial denture provided on June 16, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require 
supervision by a rehab doctor 3 times a week, or aggressive therapy by an intensive team. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for hemopneumothorax, fractured ribs and a grade II liver 
laceration after a motor vehicle collision. Your medical conditions are stable. The complexity of your nursing, 
medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 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 patient's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but 
based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy 
program. There is no documentation that the patient requires the intensive rehabilitation therapy program 
provided in an IRF. Care at the skilled nursing facility level appears to be more appropriate in this case. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay on June 18 to 
June 23, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that a representative of the 
hospital assured you repeatedly that you would not have to pay anything. The Plan denied your request. The 
Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each day in a hospital for the first five days.  
 
You have been asked to pay $1,250, or a $250 copayment for the first 5 days of an inpatient hospital stay. An 
inpatient hospital stay falls within the "Inpatient hospital care" 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 an inpatient hospital stay on June 18 to June 23, 2020.  
 
Your complaint about receiving erroneous or misleading information about your cost-sharing responsibility 
from a representative of the hospital 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the destruction of a skin growth provided on 
July 31, 2020. 
 
You asked the Plan to waive the deductible for the destruction of a skin growth. You say that the Plan did not 
pay anything toward the charges and you disagree with the charges. 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. Your 
contract with the Plan says that there is a $198 deductible for physician/practitioner services, including doctor's 
office visits.  
 
You received the destruction of a skin growth on July 31, 2020. The record shows that you had paid $0 toward 
the $198 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of 
$177.27.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $198 deductible for physician/practitioner services, including doctor's 
office visits. This cost sharing is a contractual obligation that had not been met at the time the destruction of a 
skin growth was received on July 31, 2020. Therefore, we decided that the Plan does not have to waive the 
deductible for the destruction of a skin growth provided on July 31, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the HHA services provided from January 21, 2020, to July 5, 
2020. 
 
You asked the Plan to pay for the HHA services. You say that you were told these services were already 
approved. You also say that the services are from the same HHA service from a previous HHA appeal. The 
Plan denied your request. The Plan says the enrollee did not need or receive qualified skilled services, and 
therefore does not qualify for Medicare coverage of the HHA services. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
The file shows that skilled nursing or therapy services were not provided during the dates of service at issue in 
this appeal. Therefore, we decided that the Plan does not have to pay for the HHA services provided from 
January 21, 2020, to July 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that full coverage crowns are necessary for the 
enrollee. The Plan denied your request. The Plan says this service is 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. 
 
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 pre-approve a 
core buildup, including any pins when required (D2950).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate biopsy (55700), laboratory service (88342), 
surgical pathology (G0416), cystoscopy (52000), and the transrectal ultrasound (76872) rendered by the out of 
network (OON) provider on August 19, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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. 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 prostate biopsy (55700), laboratory service (88342), surgical pathology (G0416), 
cystoscopy (52000), and the transrectal ultrasound (76872) rendered by the out of network (OON) provider on 
August 19, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency services (CPT 99285) provided to the enrollee on 
August 13, 2020. 
 
You asked the Plan to pay for the services. You say that there was a need for the services that were rendered. 
The Plan denied your request. The Plan says a secondary-only diagnosis cannot be used as the primary, first-
listed or principal diagnosis for any procedure or service. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity." 
 
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 the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found ICD-10 
R65.10 - Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ 
dysfunction, is a secondary code.  Instructions are given to "Code first underlying condition" when reporting 
this diagnosis code. 
 
We looked at this coder's review, the file, and Medicare rules. 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 emergency services (CPT 99285) provided to the enrollee on August 13, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the fracture treatment provided on April 30, 2020. 
 
You asked the Plan to pay for the fracture treatment. You say that hospice was terminated on April 28, 2020. 
You say that the claim should be processed accordingly. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 28, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the fracture 
treatment provided on April 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim was not submitted with an appropriate type of bill (TOB) code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the claim submitted cannot be paid as 
billed due to an incorrect TOB code. Medicare rules for coverage of this service have not been met. Therefore, 
we decided that the Plan does not have to pay for home health services provided to the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery. 
 
You asked the Plan to pre-approve Vertiflex superion device placement surgery. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 Vertiflex superion device placement 
surgery. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. The 
documentation does not support spinal instability. The requested device is considered experimental. More 
research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested 
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 Vertiflex superion device placement surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99215) provided July 6, 2020. 
 
You asked the Plan to pay for the physician services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say no payment will be made for any items or services 
furnished, ordered, or prescribed by an excluded individual or entity. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
is excluded from the Medicare program. Therefore, we decided that the Plan does not have to pay for physician 
services (99215) provided July 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve these services. You say that you need transportation to a medical 
appointment. The Plan denied your request. The Plan says the request exceeds the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers forty-eight one-way trips and each one-way trip must not exceed fifty miles.  
 
We looked at your request, the records in the case file, and the rules. The file shows that you are requesting a 
one-way trip for a total of 127 miles. Based on this information, we decided that the Plan?s rules for coverage 
of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional routine transportation mileage.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee has not completed her full course of care in the 
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. The enrollee 
still requires acute hospital level of care services and is receiving appropriate care at the present acute care 
hospital. The enrollee's medical needs are being met in the current acute setting. The enrollee does not require 
services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.