Persius/hicric huggingface dataset:
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 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 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted following a fall and found to be anemic. The enrollee suffered a cardiac arrest. The enrollee has developed increased interstitial opacities. The enrollee continues to receive acute critical care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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: Favorable

We decided that the Plan has to pre-approve hyperbaric oxygen (HBO) therapy (G0277 and 99183).
You asked the Plan to pre-approve HBO therapy. You say that the service is medically necessary. The Plan
denied your request. The Plan says that the member does not meet Medicare coverage criteria for this therapy.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 HBO therapy. Our reviewer says that
the requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found that the documentation indicates that the member had a Wagner grade III wound and has a poor
healing capacity.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of HBO therapy have been met. Therefore, we decided that the Plan has to preapprove
hyperbaric oxygen (HBO) therapy (G0277 and 99183).
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: 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 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 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted following being found unresponsive and with acute respiratory failure. The enrollee is noted to have seizure activity and extensive parietal-occipital cortical restrictive diffusion. The enrollee remains critically ill. The enrollee continues to receive acute critical care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that the enrollee is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically
necessary.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify
for oxygen solely based on blood gas studies obtained during sleep.
To qualify for home oxygen, the patient must meet one of the following blood gas levels:
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during
sleep for a patient who have hypoxia symptoms during sleep;
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for
patients who have hypoxia symptoms during exercise;
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of
dependent edema, pulmonary hypertension, or erythrocythemia.
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air,
there is a rebuttable presumption of non-coverage.
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 portable oxygen concentrator. Our
reviewer says that the documentation does not support that the requested item is medically reasonable or
necessary. Our physician reviewer found you desaturate with walking to 88%. However, testing did not include
verification that the oxygen saturation improved with supplemental oxygen while walking. This is necessary to
meet Medicare criteria for portable oxygen. In addition. the typical portable oxygen setup involves small
compressed air tanks, which can be refilled from a stationary concentrator. The medical records do not indicate
why that system would not meet your needs for mobility within the home. Medicare does not cover portable
oxygen systems for travel. Therefore, you do not meet criteria for the requested items.
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 portable oxygen concentrator have not been met. Therefore, we decided that
the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment.
You asked the Plan to pre-approve Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment. You say that the requested Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment. Our reviewer says that the enrollee meets criteria for the requested Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment. Our physician reviewer found based on the information provided this enrollee does meet the clinical criteria for the use of TMS therapy utilizing LCD L33398 as records submitted showed this enrollee was suffering from Major Depressive Disorder, Recurrent Episode, Severe without Psychotic Features. The enrollee had been tried on different medications and documentation shows that the enrollee had been in psychotherapy. The records indicate this enrollee does have an indication for the requested Transcranial Magnetic Stimulation (TMS) and does meet the criteria for the use of this procedure in the treatment of depression. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment have been met. Therefore, we decided that the Plan has to pre-approve Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services and the molecular pathology
procedure provided on October 15, 2020.
You asked the Plan to pay for the laboratory services and the molecular pathology procedure. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed
are not supported by the documentation.
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 the laboratory services are not supported in the medical record. Specifically, the laboratory
services should be billed with code 81479. The plan has approved the laboratory services to be bundled into
code 81479. Code G0452 (Molecular pathology procedure; physician interpretation and report) is not supported
by the documentation because the documentation does not contain a separate physician interpretation for these
services. Therefore, code G0452 cannot be verified. Based on this information, we decided that Medicare rules
for coverage of the laboratory services and the molecular pathology procedure have not been met. Therefore,
we decided that the Plan does not have to pay for the laboratory services and the molecular pathology
procedure provided on October 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection.
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested epidural steroid injection.
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 an epidural steroid injection. Our reviewer says that the enrollee does not meet criteria for the requested epidural steroid injection. Our physician reviewer found the enrollee has chronic low back pain with radicular symptoms. He is not taking any pain medications. He is doing Physical Therapy. His MRI shows either a disc or facet cyst which abutts the L4 nerve root. He has had 2 Epidural Steroid injections which have helped the Left sided pain, but the Right sided pain remains unchanged. The request is for a Transforminal Epidural steroid injection. Having had 2 prior Epidural Steroid injections which have not improved the Right sided pain, the request is deemed 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 an epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the outpatient hospital services provided
July 20, 2019.

You asked the Plan to waive the co-payment for the outpatient hospital services. You say that you believe your
co-payment is incorrect. The Plan denied your request. The Plan says the co-payment has processed correctly in
this case.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350
co-payment for outpatient hospital surgery, including services provided at hospital outpatient facilities.

You have been asked to pay $279 for the outpatient hospital services which is less than the required $350
co-payment. These services fall within the outpatient hospital surgery, including services provided at hospital
outpatient facilities. 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 co-payment for the outpatient
hospital services provided July 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on January 5, 2021.
You asked the Plan to reimburse you for the eyeglasses. You say that you are on low income and you could purchase quality eyeglasses from this provider at a lesser cost to you. The Plan denied your request. The Plan says the service sought or obtained by the member was or will be rendered by a provider who is not under contract with the Medicare Health Plan.
Medicare generally does not cover routine 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 covers these services when provided from a network provider.
We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by the Plan's network provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).

You asked the Plan to pre-approve a partial upper denture. You say that you have had several issues with your previous dentures and were unable to have them resolved sooner due to medical issues. The Plan denied your request. The Plan says this service was previously covered in January 2020 and therefore the requested service is not eligible for coverage at this time.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a partial upper denture once every five years.

We looked at the file and Medicare rules. The Plan provided documentation showing that a partial upper denture was previously covered on January 7, 2020. Based on this information, we determined that the Plan's frequency limit for coverage of a partial upper denture has already been met. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies provided from February 6, 2021, through March 4, 2021.

You asked the Plan to pay for incontinence supplies. You say that these supplies are prescribed by my doctor. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies provided from February 6, 2021, through March 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities provided on January 22, 2021.

You asked the Plan to pay for the therapeutic activities. The Plan denied your request. The Plan says the documentation submitted on appeal consists of duplicates of medical documents previously reviewed.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the
therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities provided on January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out of network (OON) provider on October 7, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out of network (OON) provider on October 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental appliance (mouth guard) to be covered under the medical benefit.
You asked the Plan to pre-approve a mouth guard under the medical benefit. You say that this mouth guard is medically necessary and should be covered by the Plan. The Plan denied your request. The Plan says this mouth guard is a dental benefit and would need to be submitted by your provider through Plan's dental. Maximus overturned the Plans denial stating this mouth guard is medically necessary. The Plan requested a reopen and stated that the issue was not medical necessity but that the provider needed to send this for coverage under the Plan's benefit. The Plan states they will work with the provider and Plan's to assist in requesting for the appropriate coverage.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. This item is considered a dental appliance and is only covered under the dental benefit. The Plan is coordinating coverage under the dental benefit. Therefore, we decided that the Plan does not have to pre-approve a dental appliance (mouth guard) to be covered under the medical benefit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services provided from September 14, 2020, to September 25, 2020.
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that you cannot afford the copayment. 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 $325 copayment per day for days 1-6 for Inpatient Hospital Care. You have been asked to pay a $325 copayment per day for days 1-6 for the inpatient rehabilitation services. The inpatient rehabilitation services fall within the Inpatient Hospital Care 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 inpatient rehabilitation services provided from September 14, 2020, to September 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 4, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 the laboratory services are not supported in the medical record. Specifically, the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical documentation and confirm that Medicare coverage criteria have been met. There is insufficient documentation to corroborate the services to confirm Medicare coverage has been met. Several requests for medical records but no records were received by the Plan. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 4, 2021.