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

We decided that the Plan has to pre-approveinpatient psychiatric services.You asked the Plan to pre-approveinpatient psychiatric hospital services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services are not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee was brought to the emergency room with belligerent behavior, medication refusal, paranoid beliefs, and auditory hallucinations. She was diagnosed with psychosis with delusions. She had thoughts of self-harm and documented impairment of memory, insight, and judgment. The records support that the enrollee would improve in a reasonable period of time and that the acute inpatient level of care is medically necessary. The services are for active treatment and the services are reasonably expected to improve the enrollee's condition and for the purpose of diagnosis. Inpatient psychiatric services are reasonable and medically necessary for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have been met.Therefore, we decided that the Plan has to pre-approveinpatient psychiatric services.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four testing (95999) provided on January 2, 2020.You asked the Plan to pay fortrain of four testing. You say that this is a covered service.The Plan denied your request. The Plan says this code 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.We find that CPT code 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other intraoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four testing (95999) provided on January 2, 2020
Appeal type: Transportation
Decision: Favorable

We decided that the Plan does not have to waivethe $240 copayment charged for ambulance transport provided on January 30, 2020.You asked the Plan to waivethis copayment. You say that you do notbelieve this copayment is correct.The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement. Maximus overturned the Plans denial stating it did not appear the Plan paid its share. The Plan requested a reopen and provided additional information to show they paid $508.78 toward this transport and the enrollee's $240 copayment was correct.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 $240 copayment for each one-wayambulance transport. The records show the Plan has paid its share of this claim. 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 waivethe $240 copayment charged for ambulance transport provided on January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea heavy duty manual wheelchair and a transfer bench.You asked the Plan to providea heavy duty manual wheelchair (K0006) and a transfer bench (E0247). You say that the enrollee needs a heavy duty manual wheelchair and a transfer bench.The Plan denied your request. The Plan says the notes do not show a mobility deficit or a home assessment and transfer benches are not covered by Medicare.The Plan follows Medicare rules. Medicare rules say that a manual wheelchair will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, or the patient's condition can be ameliorated by a walker or cane, or the enrollee's home does not provide adequate access for use of the manual wheelchair.Medicare rules say that transfer benchesare not covered because they are not primarily medical in nature. While a transfer benchmay be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.There is no documentation of the mobility deficitor home assessment. Therefore, we decided that the Plan does not have to providea heavy duty manual wheelchair and a transfer bench.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neuromuscular electrical stimulation device (NMES).
You asked the Plan to pre-approve the NMES. You say that you require the device to help you walk. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria.
The Plan follows Medicare rules. Medicare rules say that a NMES/FES device is only covered for Walking with Spiral Cord Injury. 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 NMES. Our reviewer says that the service is not medically necessary. Our physician reviewer found the records provided for review do not support that the member has a history of a SCI, rather, they have MS.
The member otherwise does not meet all of the other requirements for coverage. Specifically, they do not meet the following requirement: "Persons with at least 6-month post recovery spinal cord injury and restorative surgery;" (The member has not undergone SCI restoration surgery due to a lack of a history of a SCI). Therefore this item would not be eligible for coverage. 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 NMES have not been met. Therefore, we decided that the Plan does not have to pre-approve a neuromuscular electrical stimulation device (NMES).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the complete
series x-ray (D0210) provided on October 13, 2020.
You asked the Plan to pay for the dental services. You say that the last oral exam and x-rays that you had done
were in 2018. You say that you have been very ill and it has caused you to have a lot of teeth problems. You
say that you had to have the x-rays done again this year because your old ones were no longer accurate. The
Plan denied your request. The Plan says comprehensive oral evaluations are covered once every 3 plan years.
The Plan says that complete series x-ray is covered once every 3 plan years. The Plan also says that the
frequency limits for these services have been exceeded.
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 frequency limits of 1 every 3 plan
years have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and
complete series x-ray that you received on August 20, 2018, less than 3 years ago. Therefore, we decided that
the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the complete series x-ray
(D0210) provided on October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on July 23, 2020.You asked the Plan to pay forthe services. The Plandenied 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 forthe medical services provided to you by an out-of-network provider on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveradiofrequency ablation (CPT 64625) for the enrollee.You asked the Planto pre-approvethe procedure. You say that the requested procedure is less invasive and reduces pain.The Plandenied your request. The Plansaysthe requested procedure is not medically necessary at the sacroiliac joint.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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure because of the wide variation in efficacy. Therefore, the request is considered not medically reasonable or necessary.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 procedure have not been met.Therefore, we decided that the Plandoes not haveto pre-approveradiofrequency ablation (CPT 64625) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions (D1330), preventive procedure (D1999), and complete maxillary denture (D5110) provided on August 15, 2020.
You asked the Plan to pay for the oral hygiene instructions, preventive procedure, and complete maxillary denture. You say that you were told that your insurance company would pay the balance of these services. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. The Plan also says that you signed a financial agreement with your provider acknowledging that you would be responsible for the fees for these uncovered services.
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 oral hygiene instructions (D1330), preventive procedure (D1999), and complete maxillary denture (D5110) provided on August 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing forthe services provided on June17, 2020.You asked the Plan to waive the cost-sharing forthe services. You say that your copayment should only be $250.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a lidocaine injection (CPT Code J2001), extracapsular cataract removal (66984) and posterior chamber intraocular lens (V2632) on June 17, 2020. You were asked to pay a $250 copayment for the surgery services. You have been asked to pay 20% coinsurance of the allowed amount for prescription drugs. The allowed amount is $7.98. The total you owe for the lidocaine injection is $1.60 ($7.98 x 20% = $1.60). You have been asked to pay 20% coinsurance of the allowed amount for prescription drugs. The allowed amount is $365.95. The total you owe for the lidocaine injection is $73.13 ($365.95 x 20% = $73.13). Your total cost share responsibility for the injection, DME and surgical services you received on June 17, 2020, is $251.82 ($250 + $73.13 + $1.60 = $324.79). Your 2020 EOC states, 20% coinsurance for DME, 20% coinsurance for any Medicare Part B Covered Drugs and a $250 copayment for surgery 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 cost-sharing forthe services provided on June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvea semi-electric hospital bed.You asked the Plan to pre-approvea semi-electric hospital bed. You say that the enrollee meets criteria for the requested semi-electric hospital bed.The Plan denied your request. The Plan says that the enrollee does not meet criteria for the requested semi-electric hospital bed.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.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 a semi-electric hospital bed. Our reviewer says that the enrollee meets criteria for the requested semi-electric hospital bed. Our physician reviewer found the enrollee is with chronic obstructive pulmonary disease (COPD) and heart failure. She is noted to require the head of the bed raised at least 30 degrees.  A request for a semi-electric hospital bed was made which was appropriate and meets criteria as the enrollee breaths better with the head of bed elevated due to heart failure and COPD.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed have been met.Therefore, we decided that the Plan has to pre-approvea semi-electric hospital bed.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 pay fora knee brace (L1820) provided to the enrollee on May 8, 2020.You asked the Plan to pay forthe knee brace. You say that the service is necessary.The Plandenied your request. The Plan says you did not include a physician order or proof of delivery for the knee brace.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 physician order or proof of delivery for the supplies provided in this case. 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 fora knee brace (L1820) provided to the enrollee on May 8, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 27, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that you have a hand problem where you can't hold
items, because your hands are always shaking. The Plan denied your request. The Plan says this 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 the monitor. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the monitor is not therapeutic as glucometer is appropriate. There is no mention of you taking insulin
regularly and there was no mention of frequent changes in medication needed.
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 monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the anesthesia services (01936 QZ) provided on September 17, 2020.
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration because this service was billed correctly. The Plan denied your request. The Plan says that this claim was not billed with an appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 01936 QZ is supported in the record. Specifically, this claim was billed with modifier QZ, indicating that these services were rendered by a CRNA. The record supports that these services were rendered by a CRNA. Additionally, the Plan has not forwarded information to support why this modifier is not appropriate. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find in your favor. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have been met. Therefore, we decided that the Plan has to pay for the anesthesia services (01936 QZ) provided on September 17, 2020.
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: Favorable

We decided that the Plan has to pre-approve a replacement of a group 2 power wheelchair and accessories.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says that Medicare does not cover a replacement power wheelchair if power wheelchair is less than five years old.
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. Our doctor reviewer found that the plan has not substantiated their denial in this case. There are no objective medical records provided to indicate that the requested repair is medically necessary. A review of the case file shows that the plan had access to medical records from an office visit on 11/2/20. The plan neglected to provide these medical records to us. Therefore, we decided that the Plan has to pre-approve a replacement of a group 2 power wheelchair and accessories.
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-approvea single upright prefabricated off-the-shelf knee orthosis (L1851) for the enrollee.You asked the Plan to pre-approvethe orthosis. You say that the requested device is medically necessary.The Plan denied your request. The Plan says the requirements for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that items andservices 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 orthosis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee has no evidence of a recent surgical procedure, knee instability, or exam findings of joint laxity. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to the guidelines. The criteria for coverage have not been met.  Therefore, the requested orthotic knee brace is not reasonable or necessary.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 orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approvea single upright prefabricated off-the-shelf knee orthosis (L1851) for the enrollee