Persius/hicric huggingface dataset:
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services he needs in other settings.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a non-healing foot ulcer and below the knee amputation. The enrollee's medical problems are stable. There are no complex
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on September 15, 2020.
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 due to the enrollee's hospice status at the time of service, this claim must be reviewed by Original Medicare first.
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 medical services provided to the enrollee on September 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for magnetic resonance imaging (MRI) and positron emission tomography (PET) scans provided on October 20, 2020 and December 14, 2020.
You asked the Plan to waive the cost-sharing for MRI and PET scans. You say that in the previous year you did not have to pay a deductible for an MRI and feel that this coverage change was done stealthily by the Plan. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct. 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 $800 deductible and $180 copayment for MRI and PET scans. At the time these claims were processed, $0 of the $800 deductible had been met. The allowed amounts of these tests total $2,365.67, resulting in a deductible amount of $800 because this amount meets the $800 total deductible for 2020. The remaining allowed amount of the PET scan on December 14, 2020 is $1,565.67, resulting in a copayment amount of $180. Your total cost-sharing obligation is therefore $980. You have been asked to pay $800 deductible and $180 copayment for MRI and PET scans. MRI and PET scans fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost-sharing for magnetic resonance imaging (MRI) and positron emission tomography (PET) scans provided on October 20, 2020 and December 14, 2020.
Your complaint regarding the change in cost-sharing for this health plan contract is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on March 12, 2021.

You asked the Plan to waive the copayment for laboratory tests. You say that you were told by the provider that the test would be fully covered. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for laboratory tests. 

You have been asked to pay the allowed amount of $14.33, which is less than the $20 copayment for laboratory tests. Laboratory tests fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory tests provided on March 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the thoracic-lumbar-sacral orthosis (L0457) provided April 27, 2021.
You asked the Plan to pay for the orthosis. You say that the medical records and doctor's order clearly demonstrate medical necessity for the devices prescribed. The Plan denied your request. The Plan says the records do not support the billed service.
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, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the documentation did not include proof of deliver, a delivery ticket or an itemized billing/shipping invoice. 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 for the thoracic-lumbar-sacral orthosis (L0457) provided April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy provided on April 20, 2021 by an OON provider.
You asked the Plan to pay for the endodontic therapy. You say that you feel this service should be covered or the copay should be waived. The Plan denied your request. The Plan says this service was rendered by an OON provider.
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 endodontic therapy provided on April 20, 2021 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the partial foot, molded socket, ankle height, with toe filler (CPT code L5010), for the enrollee.
You asked the Plan to pre-approve the partial foot. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says L5000 custom made inserts, as ordered by physician, and were delivered January 29, 2021, based on notes provided.
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 partial foot have not been met. While the prosthetist (vendor) states the member needs L5010 molded socket partial foot, per Medicare guidelines, "Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for determining that an item is reasonable and necessary." The prosthetist is the vendor and therefore has financial interest in the outcome of the claim. Signed physician order is for L5000 custom made inserts, which note indicate were delivered January 29, 2021. Given this information, the request for L5010 molded socket partial foot exceeds member's need and cannot be covered. Therefore, we decided that the Plan does not have to pre-approve the partial foot, molded socket, ankle height, with toe filler (CPT code L5010), for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve additional services. You say that the enrollee will lose the mobility that she has gained. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 additional services. Our physician reviewer found that the additional requested therapy is not generally accepted as effective therapy for the enrollee's condition beyond what was approved by the Plan. The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment, that the services can be performed only by a therapist, or under the supervision of a therapist.
The requested services are not part of a maintenance program. The specialized skill of a qualified therapist is not required to establish, design or deliver a program to maintain the enrollee's current condition or to prevent/slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the oncology office visit you had on April
22, 2021.
You asked the Plan to waive the copayment for the oncology visit. You say that you did not actually see the
doctor on this date, so you shouldn't have to pay a copayment. You say that due to your anxiety, you were
unable to stay and wait to see the doctor on that date. The Plan denied your request. The Plan says you were
charged this copayment correctly. The Plan also says that the records show that you were indeed seen by the
doctor on this date, but it was a limited exam because you would not undress or allow the doctor to perform a
physical exam.
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 $45
copayment for visits to a specialist's office.
You have been asked to pay a $45 copayment for the oncology visit. The oncology visit falls within the visits
to a specialist's office benefit category. This means that you have been asked to pay the correct amount based
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the
oncology office visit you had on April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lithium battery back-up for CPAP therapy machine (CPT code A9270).
You asked the Plan to pre-approve the item. You say that the electricity constantly goes out in your home and you use your CPAP machine at night, so you request a battery that can connect your CPAP when you do not have electricity. The Plan denied your request. The Plan says this item is not covered by Medicare or the health plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Alternative power sources are not considered by Medicare as durable medical equipment. Medicare does not allow payment for power generators or alternative power sources needed in the event of power outages. Therefore, we decided that the Plan does not have to pre-approve lithium battery back-up for CPAP therapy machine (CPT code A9270).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on November 27, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim and Medicare denies coverage for all cardiovascular risk assessment tests/panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on November 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2377, E2313, E2311).
You asked the Plan to pre-approve the expandable controller. You say that the controller is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically necessary. 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 expandable controller. Our reviewer says that the requested controller is not medically necessary. Our physician reviewer found the records show that the enrollee can operate the standard functions with assistance. There is no documentation provided to show why the expandable controller is medically 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 expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2377, E2313, E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on March 25, 2021.
You asked the Plan to waive the copayment for arthrocentesis. You say that you disagree with the surgical
charges because you only received an injection. The Plan denied your request. The Plan says the claims were
processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You received arthrocentesis on March 25, 2021, at an outpatient hospital facility. Arthrocentesis is considered
an outpatient surgical procedure. Therefore, you are responsible to pay the $250 copayment.
You have been asked to pay a $250 copayment for arthrocentesis. Arthrocentesis falls within the outpatient
surgery, including 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 waive the copayment for arthrocentesis provided on March 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require aggressive therapies by an intensive team to regain function.
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 physician reviewer found that you were admitted to the acute care hospital for fluid overload, and for an infection of the foot requiring antibiotics and a partial foot amputation. Your medical problems are stable. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
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 ten (10) additional 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 that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program and you are at a high functional level. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on October 5, 2020.
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 due to the enrollee's hospice election at the time of service, this claim must be submitted to Original Medicare first.
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 medical services provided to the enrollee on October 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan you had on March 29,
2021.
You asked the Plan to waive the copayment for the duplex scan. You say that when you had lab work on March
26, 2021, the lab tech bruised you, causing you to need the duplex scan. You said that you should not have to
pay anything for the duplex scan and that the Plan should retract payment for the lab work. The Plan denied
your request. The Plan says you were charged this copayment 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 $45
copayment for routine radiology services.
You have been asked to pay a $45 copayment for the duplex scan. The duplex scan falls within the routine
radiology services benefit category. This copayment applies regardless of the reason for the scan. 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 duplex scan you had on March 29, 2021.
Your complaint about the Plan retracting payment for lab services you received on March 26, 2021, is not a
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the
Plan. Medicare does not permit us to make a decision about these types of complaints.