Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive copayment a laryngoscopy (31575) provided November 25, 2020.

You asked the Plan to waive copayment the laryngoscopy. You say that the copayment was less in the past. 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 $260 copayment for Outpatient Hospital services. 

You have been asked to pay the Medicare allowed amount of $160.26 for the laryngoscopy. The laryngoscopy falls within the Outpatient Hospital services benefit category. The allowed amount is less than the $260 listed in the plan contract. 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 copayment a laryngoscopy (31575) provided November 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient rehabilitation services provided to the enrollee from September 26, 2019, to October 20, 2019.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and states that the provider has billed an incorrect revenue code. The Plan stated the claim shows the revenue code billed was 0138 defined as "Room and Board-Three and Four Beds-Rehabilitation, with Type of Bill Code 112 indicating "inpatient hospital interim." The Plan states the provider should have billed revenue code 0024 for "inpatient rehab facility" for prospective payment system (PPS) and the CMG code as is a "Rehab Facility."

The Plan is correct in this case. 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 this claim cannot be paid as billed due to the omission of an appropriate revenue code. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for inpatient rehabilitation services provided to the enrollee from September 26, 2019, to October 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging interpretation services provided to the enrollee on August 17, 2020.

You asked the Plan to pay this claim. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. The Qualified Independent Contractor (QIC) overturned the Plans denial for insufficient claim information. The Plan requested a reopen and provided additional information. The Plan says that this claim was billed with an inappropriate place of service code. The medical records received do not mention the status of the enrollee and do not contradict what was found in claims history. The claim image shows the provider billed this service with Place of Treatment Code 22 for Outpatient Hospital; but the enrollee was listed as inpatient status from August 15, 2020 to August 23, 2020 and was admitted into ICU. The medical records show this service was rendered by the physician at the workstation. Therefore, it was denied for inappropriate billing, as it indicates this service was rendered on August 17, 2020 and billed as an Outpatient Hospital Service, in error.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate place of treatment code. In this case this clam cannot be paid as billed due to an error in the place of treatment code submitted. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for the interpretation of the coronary computed tomography (CT) scan provided to the enrollee on August 17, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from July 10, 2020, to July 13, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request stating the claim was submitted with billing errors. The Qualified Independent Contractor overturned the Plans denial. The Plan requested a reopen and stated that this claim denied because it was submitted inappropriately without the discharge code. The Plan states the record indicates that the enrollee was admitted and discharged on July 13, 2020, validating the same day transfer condition code. However, the case file includes the claim image that shows the provider has billed this service for the dates of July 10, 2020, through July 13, 2020 yet the records only show the enrollee was admitted and discharged for only one date of service which was July 13, 2020. This claim cannot be paid because the provider incorrectly billed the claim for multiple dates of service when the records show the enrollee was admitted and discharged on the same day.

The Plan is correct in this case. 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 does not coincide with the dates of service reported in the medical records. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care provided to the enrollee from July 10, 2020, to July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to be provided by a non-contracted provider.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the provider is not in-network and there are network providers available to provide the 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 a consultation to be provided by a non-contracted provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 test provided on July 6, 2020.

You asked the Plan to pay for the COVID-19 test. You say that you have no knowledge of the enrollee's coverage prior to the specimen's arrival at the laboratory. 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 COVID-19 test provided on July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on October 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 nursing facility care provided on October 19, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (01638) provided on October 27, 2020.

You asked the Plan to pay for anesthesia services. You say that this was billed with valid diagnosis codes. The Plan denied your request. The Plan says the billed diagnosis codes do not correctly indicate laterality.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. 

We find that the billing of diagnosis code Z96.619, presence of unspecified artificial shoulder joint, is not supported in the medical records. Specifically, the records indicates that the condition occurred on the left side, meaning it is not appropriate to bill a diagnosis code with unspecified laterality. Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (01638) provided on October 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that a skilled nursing facility is not the appropriate level of care at this time. The Plan denied your request. The Plan says the enrollee can adequately receive the care needed in the current location.

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 physician reviewer found that the enrollee was admitted to the current acute care hospital with hypoxemic hypercarbic respiratory failure with encephalopathy related to cirrhosis. Current notes state that the enrollee's current prognosis was guarded, and he was still encephalopathic but gradually improving. The enrollee requires additional short-term acute care services to continue weaning which can safely be completed at the current facility. He does not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time.

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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for outpatient hospital services provided to the enrollee on July 1, 2020.
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 Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that this claim denied because the provider has billed inappropriately with the incorrect revenue code. The claim image shows the provider has billed with revenue code 0300 defined as "Laboratory-General." The provider should have billed revenue code 0510 defined as "Clinic-General" classification. The Plan states the Medicare Claims Processing Manual Chapter 19, Section 100.5, states "All charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue code 0510 (clinic visit) on Type of Bill 13X (hospital outpatient)".
The Plan is correct in this case. 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, this claim cannot be paid as billed due to an error with the revenue code reported. Medicare billing requirement are not met. Therefore, we decided the Plan does not have to pay for outpatient hospital services provided to the enrollee on July 1, 2020.
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 in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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 an infected wound on left foot and had an above the knee amputation. Medical problems are stable. 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bathtub wall rail.
You asked the Plan to pre-approve the rail. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a Medicare-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 bathtub wall rail.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the wide area transepithelial sampling (88361, 88312, 88305 and 881040) provided on June 10, 2020.
You asked the Plan to pay for the wide area transepithelial sampling. You say that you would like reconsideration because the billed services were requested by the member's physician and medically necessary. The Plan denied your request. The Plan says the professional interpretation of a diagnostic test must be separately billed with modifier - 26 by the interpreting physician.
The Plan must follow Medicare rules. Medicare rules say that if a diagnostic test which has a separate TC and PC is provided under arrangement to a hospital, the physician who reads the test can bill and be paid for the professional component. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wide area transepithelial sampling have not been met. Specifically, the professional component of these codes is separately billable by the physician who reads the test. The professional component requires the use of modifier 26. Therefore, we decided that the Plan does not have to pay for the wide area transepithelial sampling (88361, 88312, 88305 and 881040) provided on June 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).

You asked the Plan to pre-approve the special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan says you must have one or more chronic conditions (from a list of specific conditions identified by your health Plan) that are medically complex, life-threatening, or significantly limiting your health or its performance in general. You do not require intensive care coordination and you do not have a high risk for hospitalizations or high risk for adverse health outcomes.

The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination.

We looked at the file and Medicare rules. The file shows that your medical conditions are not eligible medical conditions under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy sessions (90834) provided on November 17 and November 24, 2020, by an OON provider.
You asked the Plan to pay for psychotherapy sessions. You say that the requested services were a medical necessity for the enrollee. 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 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 psychotherapy sessions (90834) provided on November 17 and November 24, 2020, by an OON provider.