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

We decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee on September 1, 2020.
You asked the Plan to pay for this claim. You say that this transport should be covered by the Plan. The Plan denied your request. The Plan says Medicare coverage criteria were not met Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for ambulance transport. Maximus determined that Medicare rules say that the list of allowable destinations for ambulance transports has expanded during the public health emergency. Based on the emergency ruling information, it was determined that Medicare rules for coverage have been met. The Plan argues that there is no documentation of urgency, inability to ambulate or restricted locomotion, or of contraindication of use of another method of transportation. Therefore, the relaxed rule during the pandemic would not apply, as this was a convenience choice of the member and the facility. The medical records show the enrollee was a then 85-year-old woman with a reported episode of bladder bleeding one month prior. The enrollee was brought to a health pavilion for an appointment with urology. Vital signs were unremarkable. The enrollee was transported into the facility via cot and remained stable. She was left on the cot during the exam. The enrollee was then loaded and secured in the ambulance and was transportedl. Our Medical Director has concluded the Plan is correct in this case. While CMS temporarily expanded the list of allowable destinations for ambulance transports to include physician's offices, the general coverage rules for ambulance transport still apply. The documentation does not support that the another means of transport, such as a stretcher van, was contraindicated for the enrollee at the time of transport. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on the date of transport. The documentation does not support that the ambulance transport was medically reasonable and necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee on September 1, 2020.
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 transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
At issue is coverage for LTACH services. The Maximus Physician Reviewer determined that you had a long, complicated medical history which included a GI bleed, respiratory failure requiring tracheostomy, and renal failure. The medical records indicated a likely need to be on and off a respirator in the weeks ahead, with special nursing to assess the respiratory status on a regular basis. You also needed to be seen by a physician daily to assure stability of his chronic active medical conditions. The Plan states that you had not completed his full course of care in the acute care hospital. The plan also notes that the doctors were still evaluating the gallbladder and you had a recent high fever. The medical records show you have a history of stroke, COVID-19, pneumonia, chronic respiratory failure, diabetes, hypertension, sleep apnea, and chronic kidney disease. You were admitted to the acute care hospital on September 26, 2020 with respiratory failure. A tracheostomy was placed on October 19, 2020. On November 4, 2020 you were receiving antibiotics for a urinary tract infection. Worsening cholestasis was documented, and a blood test and ultrasound were planned. Our Medical Director has concluded the Plan is correct in this case. The documentation does not support that you require services at the LTACH that were not available at the acute care hospital where he was receiving care. The documentation did not support that LTACH services were medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at the time of the determination. Medicare coverage criteria for transfer are or were not 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of a LTACH admission. 
 
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 that the enrollee had two surgeries for gangrene of the foot while admitted. The 
enrollee had a right foot partial first ray resection with placement of a wound vac. The enrollee then had repeat 
debridement of non-viable tissue with application of an integra biological skin graft and a wound vac to assist 
with the granulation process. The enrollee needs hyperbaric oxygen therapy and ongoing IV for osteomyelitis 
treatment and monitoring of healing. There is no documentation provided necessitating admission to a LTACH. 
The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require 
services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 LTACH services.
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 you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission 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 enrollee required maximum assistance to sit up and to scoot. The enrollee 
required moderate assistance to lie down. The documentation does not support that the enrollee requires an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does 
not support that the enrollee requires an intensive rehabilitation therapy program. 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: 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 these are necessary for you to live and move 
around independently. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar orthosis provided on November 12, 2020. 
 
You asked the Plan to pay for the provided orthosis. The Plan denied your request. The Plan says the enrollee 
was not seen by the referring provider for any service to justify the ordering of the equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that lumbar orthoses are only covered under certain 
medical indications.   
 
We looked at the file and Medicare rules. The records show the enrollee has low back pain. The medical 
records do not indicate the enrollee's condition requires an orthosis to reduce pain by restricting mobility, is 
healing from an injury or surgical procedure, or needs support for weak spinal muscles or a deformed spine. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the lumbar orthosis provided on November 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services.

You asked the Plan to pay for inpatient services. You say that the Plan should pay this claim. The Plan denied
your request. The Plan says Original Medicare is responsible for this claim.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits. The inpatient services in question were provided before the 
end of that month. A benefit period begins the day the enrollee is admitted as an inpatient in a hospital. 
The benefit period ends when the enrollee has not received any inpatient hospital care for 60 days
in a row. The enrollee was still in the benefit period started under hospice. Original Medicare is responsible for
this claim. Therefore, we decided that the Plan does not have to pay for the inpatient services.
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 routine transportation. You say that you need an additional ride for your 
appointment. The Plan denied your request. The Plan says the denial of authorization for additional routine 
transportation is correct, because routine transportation beyond 10 one-way trips per year is not covered by the 
Plan. 
 
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 transportation trips.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EKG and EKG services provided by a
participating hospital on November 4, 2020, to November 6, 2020.
You asked the Plan to waive the copayment for an EKG and EKG services. You say that you were told that you
would only have one copayment. The Plan denied your request. The Plan says the correct copayment has been
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 $190
copayment for outpatient diagnostic tests/diagnostic procedures and tests/outpatient hospital.
You have been asked to pay a $190 copayment for an EKG and EKG services. The total amount you are being
asked to pay is $302.96 ($190 + $112.96 = $302.96) which is less than your copayment amount of $380 ($190
x 2 = $380). An EKG and EKG services fall within the outpatient diagnostic tests/diagnostic procedures and
tests/outpatient hospital 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 an EKG and
EKG services provided by a participating hospital on November 4, 2020, to November 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99212) provided October 
27, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that the copayment should be waived. 
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 $35 
copayment for specialist visits.  
 
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the specialist 
visits 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 an office visit (99212) provided 
October 27, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
August 1, 2020, to August 5, 2020. 
 
You asked the Plan to pay for the SNF services. You say that the skilled nursing facility stay was medically 
necessary. The Plan denied your request. The Plan says there was no authorization for the skilled nursing 
facility stay. The Plan says the facility is out of network. The Plan also says that without clinicals, the medical 
necessity of the stay cannot be determined. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for the SNF services. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided from August 1, 2020, to August 5, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D3320) and resin-based composite 
(D2391) provided on October 12, 2020. 
 
You asked the Plan to pay for the dental services. You say that you believed this provider was in-network, and 
you were referred by your primary dental provider. The Plan denied your request. The Plan says this provider is 
not in the Plan's network, and out-of-network care is not covered. No referral was submitted for review and 
there were other dental providers in the Plan's network who would have been able to provide this care. 
 
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, these services are not covered outside 
the Plan's network. Therefore, we decided that the Plan does not have to pay for the endodontic therapy 
(D3320) and resin-based composite (D2391) provided on October 12, 2020.  
 
Your complaint about possible misinformation from either the Plan or the Plan's supplemental dental benefit 
provider 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on 
November 18, 2020. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you believe this service 
should be covered. The Plan denied your request. The Plan says this service 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 pay for the 
complete series of intraoral x-rays provided on November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1833) and suspension sleeve (L2397) 
provided October 13, 2020 
 
You asked the Plan to pay for the orthoses. You say that you received the denial letter stating evidence of 
misrepresented services. It went straight to denial without the opportunity to submit the documentation to prove 
these services where in fact a medical necessity. The Plan denied your request. The Plan says there is no 
evidence of an established relationship between the enrollee and the ordering physician, there was no claims 
submitted for an evaluation and management service and there is no evidence of a prior telehealth service with 
the ordering physician as required per CMS guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 

 
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833) and 
suspension sleeve (L2397) provided October 13, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transport from dialysis to residence
.
You asked the Plan to pay for the non-emergent ambulance transport. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee appears to be able to sit in a wheelchair or recliner therefore alternatives to transport may include a wheelchair van or a private vehicle.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

We looked at the file and Medicare rules. The record shows the enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. The enrollee could have been safely transported by another type of vehicle. You did not request prior authorization. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transport from dialysis to residence.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged evaluation services rendered on October 24, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99358 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99358 is prolonged evaluation and management service before and/or after direct patient care; first hour. We find that CPT code 99358 is not supported in the medical record. Specifically, the records show that the provider spent 33 minutes of non face-to-face time with the enrollee. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the prolonged evaluation services rendered on October 24, 2020.