Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit and ECG to be provided by an out-of-network provider.

You asked the Plan to pre-approve the office visit and ECG. You say that you were diagnosed with systemic lymphedema and you were recommended to this doctor because he specializes in systemic lymphedema. The Plan denied your request. The Plan says cardiology services are available within your health network.

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 pre-approve the office visit and ECG to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).

You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time (99072) provided on January 11, 2021, through January 13, 2021.

You asked the Plan to pay for the additional supplies, materials and clinical staff time. You say that you would like reconsideration because this code has been added for extra expenses during COVID-19. The Plan denied your request. The Plan says CPT code 99072 is a bundled-only procedure and not separately reimbursable.

The Plan must follow Medicare rules. Medicare rules say that CPT code 99072 has a status indicator of B.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional supplies, materials and clinical staff time have not been met. Specifically, per CMS, CPT code 99072 has a status indicator of B. This means that this CPT code is a bundled-only procedure and not separately reimbursable. Therefore, we decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time (99072) provided on January 11, 2021, through January 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional ten (10) PT visits.

You asked the Plan to pre-approve an additional ten (10) PT visits. The Plan denied your request. The Plan says continued therapy can be provided with a home exercise program.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 an additional ten (10) PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had previous therapy and should be independent with a home exercise program. The additional physical therapy sessions are considered excessive and not an appropriate duration and frequency for the enrollee's medical condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an additional ten (10) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
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 you would like this service to be approved for coverage. The Plan denied your request. The Plan says this procedure 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy provided by an out-of-network provider on May 12, 2020.

You asked the Plan to pay for the psychotherapy. You say that the physician depends on the hospital staff to verify eligibility and obtain proper authorization. You say that the physician provided medically necessary services and payment for the claim should be processed at the maximum amount allowed. The Plan denied your request. The Plan says prior authorization was required but not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 psychotherapy provided by an out-of-network provider on May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chiropractic office visit.

You asked the Plan to pre-approve the services. You say that the physician did not use the correct code for subluxation. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve a chiropractic office visit.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse you the Plan benefit of $100 for eyeglasses provided on December 15, 2020.

You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says that the materials could not be processed and paid because the member opted into a promotion that the provider was offering. Plan benefits do not allow the member to be reimbursed when members opt to accept a promotion/discount from the provider.

Medicare generally does not cover eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

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.

We looked at the file, the Medicare rules and the Plan's rules. 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 has not provided evidence that the routine eyewear benefit excludes coverage when an enrollee opts into a promotion that the vision provider is offering. The file shows that the routine vision benefit provides coverage for eyewear with a $100 benefit both in-network and out-of-network. You pay any amount over $100 retail price. Therefore, we decided that the Plan has to reimburse you the Plan benefit of $100 for eyeglasses provided on December 15, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic imaging to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve diagnostic imaging. You say that this provider is closer to the member. You say that you would like approval for these services. The Plan denied your request. The Plan says there are in-network providers available for these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve diagnostic imaging to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF admission. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says that Medicare coverage criteria are not met. Maximus agreed with the Plans denial based on the medical records provided in the case file. Your advocate contacted Maximus and provided additional medical records that were not available at the time of our review.

Our Medical Director looked at the case file and the additional information sent directly to Maximus. At issue is IRF coverage. The records show you have a medical history of stroke with vascular cognitive impairment. You were admitted to the hospital on May 14, 2021 with symptomatic hypoglycemia. Mild dumping syndrome with postprandial hypoglycemia was suspected. On May 21, 2021 you ambulated 150 feet with a rolling walker and care giver assistance. You had increased knee buckling with fatigue. On May 23, 2021 it is documented that you only ambulated 50 feet with unsteady gait and episodes of his knee buckling. You were limited by impaired balance and mobility, as well as poor activity tolerance. On May 24, 2021 you ambulated 100 feet and 50 feet with a rolling walker with close chair follow, and care giver assistance for unsteadiness and buckling with fatigue. On May 26, 2021 it is documented that you ambulated only 30 feet with a rolling walker and with an unsteady gait, with bilateral knees buckling.

Our Medical Director has concluded that the additional documentation supports that the progress in therapy has reversed, and the ability to ambulate has declined. The documentation supports that you require at least 3 hours a day for 5 days a week, or 15 hours over 7 consecutive days, of therapy service, and that you are able to tolerate 3 or more hours per day of aggressive therapy. Medicare coverage criteria for IRF admission are 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abutment supported cast metal crown (D6062) for tooth # 7.

You asked the Plan to pre-approve the dental service. You say that you need to see an in network dentist for this service. You say that your referral does not mention an in network dentist. You say that you do not mind paying for the service. You also say that you need information for in network dentists to provide this service so that you can "receive 20 to 50% discount on dental services by seeing a participating dentist." The Plan denied your request. The Plan says the requested service is not listed as covered. The Plan also says that you are scheduled for an appointment with an in network dentist for an evaluation.

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 an abutment supported cast metal crown (D6062) for tooth # 7.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET scan from skull to mid-thigh (78815) with a diagnostic radiopharmaceutical (A4641) to be provided by an OON provider.

You asked the Plan to pre-approve a PET scan with a diagnostic radiopharmaceutical. You say that the requested services cannot be provided in the enrollee's state. The Plan denied your request. The Plan says rules for OON care have not been met.

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 a PET scan from skull to mid-thigh (78815) with a diagnostic radiopharmaceutical (A4641) to be provided by an OON provider.

Please note that the Plan has agreed to pre-approve an in-network PET scan with a diagnostic radiopharmaceutical. Contact the Plan to learn more about how and when to receive these services from an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that you do not want to fall while in your bathroom. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) provided on February 8, 2021.

You asked the Plan to pay for the office visit. You say that you would like reconsideration because you were referred to this provider by your neurologist. The Plan denied your request. The Plan says Medicare does not cover non-manipulative services provided by chiropractors.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99203) provided on February 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transport services (A0100).

You asked the Plan to pre-approve the additional routine transport services. You say that the transport trip is medically necessary. The Plan denied your request. The Plan says this benefit has been exhausted.

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 a maximum of 10 trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transport services (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that this requested item is medically necessary for your condition. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on December 9, 2020.

You asked the Plan to pay for the home visit. You say that the provider depends on the hospital staff to verify eligibility and to obtain the proper authorization. You say that these were medically necessary services, and the claim should be reprocessed for payment at the maximum amount allowed. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 home visit provided by an out-of-network provider on December 9, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the specialist office visit provided on January 28, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that you feel the enrollee should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says that the copayment applied correctly.

The Plan must follow Medicare rules. Medicare says that providers cannot charge enrollees for an office visit or other fee if a COVID-19 vaccination is the only medical service given. In this case, the file shows that the only service the enrollee received was a preventative service for the COVID-19 vaccination. Therefore, we decided that the Plan has to waive the copayment for the specialist office visit provided on January 28, 2021.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation to appointments. The Plan denied your request. The Plan says that you have exhausted this benefit.
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 a maximum of twenty-four (24) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services with an out-of-network provider on December 9, 2020.

You asked the Plan to pay for the dermatology services. You say that you thought this was an in-network provider and she would not have gone if you knew they weren't in-network. You say that the bill is a lot of money and you shouldn't be responsible. The Plan denied your request. The Plan says there is no authorization on file and the provider was not contracted with the Plan at the time of service.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 dermatology services with an out-of-network provider on December 9, 2020.