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

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that you would like to stay in the hospital until a different skilled nursing facility becomes available. The Plan denied your request. The Plan says based on the documentation provided, medical necessity for inpatient hospital care has not been established.
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 pre-approve acute inpatient hospital care. Our reviewer says that the services are not medically necessary. Our physician reviewer found you presented on January 10, 2020 with complaints of swelling in bilateral lower extremities and pain/redness of right hip at site of incision from recent hip surgery. After evaluation in the Emergency Department, the treating physician documented that inpatient admission was not necessary and that medically necessary care, including oral antibiotic, diuretic and physical and occupational therapy, could be provided in the observation status. Symptoms improved and there were no new complications that developed. All medically necessary care was provided in a time period of less than two midnights. The record shows that your necessary hospital care (including earlier ED and/or observation care) is not expected to span a time period of 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 pre-approve acute inpatient hospital care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you had gotten stung and were worried about an allergic reaction. You say that you called for an ambulance which came and evaluated you. The responders assessed you and advised you that you did not need to go to the hospital. You say that you believe the Plan should cover some of the cost of the ambulance. The Plan denied your request. The Plan says these services are not a covered benefit.
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 September 11, 2019. 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 services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cervella Device (Cranial Electrotherapy Stimulators).
You asked the Plan to pre-approve the services. You say that the service is medically necessary. The Plan
denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. Although the equipment counts
with approval from FDA class III, the therapy with stimulator of cranial electrotherapy is considered
experimental, investigational and no proven for the treatment of insomnia, depression and anxiety. Therefore,
we decided that the Plan does not have to pre-approve Cervella Device (Cranial Electrotherapy Stimulators).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on June 23, 2019.
You asked the Plan to pay for the critical care services. You say that the services were medically necessary. The Plan denied your request. The Plan says the record does not support the services billed.
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 99291 is Critical Care Services, 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the records provided do not substantiate that greater than 30 minutes was spent on the critical care services. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on June 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the breast reconstruction surgery provided
on August 1, 2019.
You asked the Plan to reduce the copayment for the breast reconstruction surgery. You say that you have
confirmation letters that state you would have a $145 copayment. The Plan denied your request. The Plan says
you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including
but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay a $175 copayment for the breast reconstruction surgery. The breast reconstruction
surgery falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient
Facilities and Ambulatory Surgical Centers" benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment
for the breast reconstruction surgery provided on August 1, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to the enrollee on September 27, 2018, by an out-of-network provider.You asked the Plan to pay forthe services. You say that the provider is not aware of the patient's insurance.The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.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 forthe services provided to the enrollee on September 27, 2018, by an out-of-network provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forGuardant 360 testing provided to the enrollee on August 29, 2019.You asked the Plan to pay forthis service. You say that this testing was medically necessary.The Plan denied your request. The Plan says that the enrollee self-referredout of network for this testing without prior authorization. The Plan states the enrollee did not follow the plan contract agreement when obtaining these services.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states the enrollee self-referred out of network without prior authorization which is contradictory to the Plans contract agreement. However, the Plan failed to provide MAXIMUS with a copy of the applicable Evidence of Coverage. Without the Plan contract, we cannot substantiate the Plans denial. Therefore, we decided that the Plan has to pay forGuardant 360 testing provided to the enrollee on August 29, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power mobility device (PMD).
You asked the Plan to pre-approve a Group 2 PMD. You say that this will improve your mobility. The Plan denied your request. The Plan says that a Group 2 POV is not reasonable or medically necessary for in-home use.
The Plan must follow Medicare rules. Medicare rules say that Group 2 POVs have added capabilities that are not needed for use in the home and will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power mobility device (PMD).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Estradiol patches for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee has been stable on this medication for several years. The Plan denied your request. The Plan says that this is not a Part B drug.
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 requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Estradiol patches for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous immune globulin (IVIG) injections.
You asked the Plan to pre-approve the IVIG injections. You say that the enrollee is suffering from dysarthria and shortness of breath which could lead to respiratory failure. You state that alternative treatments may take months to work and he needs a more rapid treatment of his symptoms. The Plan denied your request. The Plan says the criteria for IVIG treatment have not been met.
The Plan follows Medicare rules. Medicare rules say that IVIG for myasthenia gravis is covered for those who have failed treatment with corticosteroids and at least one immunosuppressive agent. 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 IVIG injections. Our reviewer says that the requested treatment is not considered medically reasonable and necessary based on the LCD criteria. Our physician reviewer found in this case, the patient carries a diagnosis of myasthenia gravis. He has previously been treated with steroids; however, he developed intolerable side effects and the steroids had to be stopped. At an 11/2019 office visit, he was prescribed IVIG infusions to be provided on a monthly basis. In this case, the patient is noted to have had severe side effects due to steroid therapy. However, he has not (yet) been treated with at least one immunosuppressive agent. In as much, the requirements for coverage of IVIG as defined by the LCD have not been 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 the IVIG injections have not been met. Therefore, we decided that the Plan does not have to pre-approve intravenous immune globulin (IVIG) injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee and billed under code 99152.
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 Current Procedural Terminology (CPT) code 99152 remains not supported. The Plan states CPT 99152 represents Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time, patient age 5 years or older. The documentation submitted did not include documentation of the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; therefore, the billed service cannot be verified. Of note, an independent trained observer is someone other than the physician performing the services. It is noted that multiple attempts were made to contact the provider for additional information
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code and also provide medical records that support the services billed. In this case, the records provided are limited and do not support the services billed under code 99152. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee and billed under code 99152.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fordialysis services (90999) provided on June 3, 2019 through June 17, 2019.You asked the Plan to pay for the dialysis services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim does not have a D5 Value Code with amount nor does it have the 51 Occurrence Code with date.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code  is not supported in the medical record. Specifically, the claim does not include the required Value D5 and Occurrence 51 codes. Based on this information, we decided that Medicare rules for coverage of the dialysis services have not been met. Therefore, we decided that the Plan does not have to pay for dialysis services (90999) provided on June 3, 2019 through June 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the epidural injection provided by on July
29, 2019.
You asked the Plan to waive the copayment for the epidural injection. You say that you never spent any time in
the hospital. You say that you only had a shot and were not operated on. The Plan denied your request. The
Plan says the copayment 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 $295
copayment for surgery services at an in-network outpatient hospital.
You have been asked to pay a $295 copayment for the epidural injection. The epidural injection falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The epidural injection is considered a surgical procedure. 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 epidural injection provided by on July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the consultation (99202) and Losartan tablets provided on May 8, 2019.
You asked the Plan to reimburse you for the consultation (99202) and Losartan tablets. You say that the consultation and Losartan tablets provided were medically necessary. The Plan denied your request. The Plan says the consultation and Losartan tablets provided were neither emergent nor urgent.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 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 reimburse you for the consultation (99202) and Losartan tablets. Our reviewer says that the consultation and Losartan tablets provided were neither emergent nor urgent. Our physician reviewer found the enrollee lost his losartan tablets while on a cruise. Necessity of a medical visit to refill the prescription is in question. Based on the documentation provided for review, there are no medical records submitted with this claim. Due to the lack of medical records it cannot be determined if the visit was emergent or urgent. 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 consultation (99202) and Losartan tablets have not been met. Therefore, we decided that the Plan does not have to reimburse you for the consultation (99202) and Losartan tablets provided on May 8, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve photochemotherapy services.
You asked the Plan to pre-approve photochemotherapy. You say that you believe these services are medically necessary based on the enrollee's condition. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this service is 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 photochemotherapy. Our reviewer says that the enrollee meets the Medicare criteria for the requested photochemotherapy. Our physician reviewer found phototherapy is an accepted treatment regimen for the enrollee's conditions. The treating physician states that multiple treatment options have been tried and failed. Narrowband phototherapy has previously been used successfully. The documentation supports that phototherapy is medically reasonable and necessary for the enrollee 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 photochemotherapy have not been met. Therefore, we decided that the Plan has to pre-approve photochemotherapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular partial denture provided on July 10, 2019.
You asked the Plan to pay for the mandibular partial denture. You say that you have 4 missing front teeth. You also say that your denture still does not fit. 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 pay for the mandibular partial denture provided on July 10, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises, OT evaluation, therapeutic activities, and self-care management training provided from April 2, 2019 to April 30, 2019.
You asked the Plan to pay for the therapeutic exercises, OT evaluation, therapeutic activities, and self-care management training. You say that the services were not related to the enrollee's hospice diagnosis. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises, OT evaluation, therapeutic activities, and self-care management training provided from April 2, 2019 to April 30, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approvecore buildup (D2950) for teeth # 6, 20, and 21.You asked the Plan to pre-approvethe dental services. You say that you need crowns. You say that you need core build up in order to get the crowns. You also say that if crowns are covered, core build up should be covered too.The Plan denied your request. The Plan says that core build up is not a covered dental 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. The Plan covers the dental services when the services are medically necessary and reasonable.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 dental services. Our reviewer says that the service is medically necessary. Our physician reviewer found due to the lack of sound tooth structure of teeth # 6, 20 and 21 as noted in the documentation submitted, these teeth meet the criteria for coverage for core buildups (D2950) prior to the placement of crowns.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met.Therefore, we decided that the Plan has to pre-approvecore buildup (D2950) for teeth # 6, 20, and 21.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter