Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on February 20, 2021.

You asked the Plan to waive the copayment for the inpatient care. You say that you were not admitted as an inpatient and refused the inpatient services as soon as you were brought to another area of the hospital. The Plan denied your request. The Plan says that documentation supports you were admitted as an inpatient on February 20, 2021. You must pay a $270 copayment for each of the first six days of an inpatient hospital admission. You were admitted for one day, and therefore this copayment was applied 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 $270 copayment for each of the first six days of a Medicare-covered inpatient hospital admission.

You have been asked to pay a $270 copayment for the inpatient care. You were admitted as an inpatient on February 20, 2021, and then discharged the same day. 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 hospital care provided on February 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed.

You asked the Plan to pre-approve a heavy duty extra wide hospital bed. You say that these services are medically necessary. The Plan denied your request. The Plan says that your records show you do not have wounds that require special positioning, respiratory difficulty or aspiration risk.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 

2. Requires attachments which can only be attached to a hospital bed; AND 

3. Requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration.

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 heavy duty extra wide hospital bed. Our reviewer says that a heavy duty extra wide hospital bed is not medically reasonable and necessary. You have morbid obesity and bipolar disorder. You also have pedal and abdominal edema but do not have congestive heart failure or respiratory difficulty. You do not have any wounds or pressure ulcers. You are requesting the hospital bed to aid in transfers. Your condition does not require position of the body in ways not feasible in an ordinary bed. You do not require the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. You do not require traction equipment, which can only be attached to a hospital bed. Our physician reviewer found that your condition does not meet Medicare criteria for a heavy duty extra wide hospital bed.

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 heavy duty extra wide hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on September 22, 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 99291 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 

We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of the first 30-74 minutes of critical care services spent on 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 critical care services rendered on September 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intermittent limb compression device.
You asked the Plan to pre-approve intermittent limb compression device. You say that you are hoping the pictures will show the severity of your leg and show how the improvement is from the Normatec machine and not primarily used for peripheral arterial decrease. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for the treatment for peripheral arterial disease.
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat peripheral artery disease is not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee lives alone. You say that the enrollee is in pain and needs therapy. You say that the enrollee has moderate assistance with transfers and needs assistance with ambulation. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee does not have any daily skilled nursing needs.
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 pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee received physical therapy and occupational therapy. The enrollee was at stand-by assist to contact-guard assist with functional mobility, including gait to 75 feet. You say that you the enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for 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 pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan must waive the copayment for the collection of a blood specimen from a completely implantable venous access device.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly 
to the service provided. Maximus upheld the Plans decision and then reopened the appeal due to an error in the analysis of the case. 
 
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 does not say in clear and accurate terms 
how much you should expect to pay for the collection of a blood specimen from an implantable venous access 
device.  We looked at the file and your contract with the Plan. Based on this information, we find that you did not have a reasonable expectation that the blood draw through your implanted venous access device would be 
considered a surgical procedure. While this service may be coded as surgical, the performance of the service 
would not include many of the components that would reasonably be considered surgery by a layperson. There 
is no other benefit category in the EOC under which this service would be included other than lab testing. 
Because of this ambiguity, we find that you cannot be asked to pay more than a $0 copayment for the service at 
issue. Therefore, we decided that the Plan must waive the copayment for the collection of a blood specimen 
from a completely implantable venous access device (36591) provided on January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan must waive the copayment for the collection of a blood specimen from a completely
implantable venous access device.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly
to the service provided. Maximus upheld the Plans decision and then reopened the appeal due to an error in the
analysis of the case.

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 does not say in clear and accurate terms
how much you should expect to pay for the collection of a blood specimen from an implantable venous access
device. We looked at the file and your contract with the Plan. Based on this information, we find that you did
not have a reasonable expectation that the blood draw through your implanted venous access device would be
considered a surgical procedure. While this service may be coded as surgical, the performance of the service
would not include many of the components that would reasonably be considered surgery by a layperson. There
is no other benefit category in the EOC under which this service would be included other than lab testing.
Because of this ambiguity, we find that you cannot be asked to pay more than a $0 copayment for the service at
issue. Therefore, we decided that the Plan must waive the copayment for the collection of a blood specimen
from a completely implantable venous access device (36591) provided on August 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve the inpatient hospital admission. You say that the records provided support 
the need for an inpatient admission. The Plan denied your request. The Plan says the enrollee's aftercare can be 
provided safely in a different setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found there is no specific clinical rationale for the requested inpatient services. The enrollee is medically stable. The record does not show that at the time of the request for an inpatient 
admission the requesting physician reasonably expected that the enrollee's necessary hospital care would span 
two midnights. 
 
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 inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Practitioner Services
Decision: Unfavorable

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

We decided the Plan does not have to provide coverage for skilled nursing facility (SNF) services.

You asked the Plan to provide coverage for SNF services. You say that skilled nursing facility services are
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee has exhausted
the 100-day benefit prior to this request. Maximus overturned the Plans denial for lack of notice. The Plan
requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that enrollees are covered
for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a
hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient
hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period
between December 29, 2020, to April 28, 2020 (55 days). The Plan has covered 100 days of SNF care.
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided
that the Plan does not have to provide coverage for skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dentures.

You asked the Plan to pre-approve dentures. You say that you need dentures along with the previous outpatient surgery so you can move forward with her cancer treatments. The Plan denied your request. The Plan says dentures are excluded from coverage.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dentures.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. The requested Vertiflex Superion spacer is considered experimental/investigational in nature, as more research is needed to show safety and efficacy. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: SNF
Decision: Unfavorable

We decided the Plan did not have to provide coverage for continued skilled nursing facility (SNF) services
appealed on March 19, 2021.

You asked the Plan to provide coverage for continued SNF services. At the time of the appeal, you say that
continued SNF care were medically necessary. The Plan denied your request. The Plan says your 100 days of
coverage expired September 27, 2020. Maximus overturned the Plans denial stating the case file lacked
documentation of the 100 days used and the benefit period covered. The Plan requested a reopen and provided
additional documentation. The Plan provided documentation to show your last covered day was September 27,
2020 however due to the Corona Virus surge, you were provided with an additional 54 days up to December
31, 2020.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that enrollees are covered
for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a
hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient
hospital or SNF care.

The records provided by the Plan confirm that you were covered not only for your 100 SNF days but for an
additional 54 days due to the pandemic. Although you may still have needed skilled care, the Plan was not
required to pay for more than 100 days of SNF coverage during this benefit period and clearly covered well
over the 100-day benefit. You would not have been eligible for a new benefit period until you were not been
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the
Plan does not have to provide coverage for the continued skilled nursing facility (SNF) services in question.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) sensors.
You asked the Plan to pre-approve CGM sensors. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of CGM sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) sensors.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you need to be discharged from the hospital 
but have no one at home to assist you. The Plan denied your request. The Plan says the guidelines for SNF care 
have not been met. The Plan says that the enrollee's rehabilitation and medical needs can be met in a lower 
level of care. 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 pre-approve the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications, had stable vital signs and clear lungs. The enrollee received physical therapy and occupational 
therapy. The enrollee was at a modified independent level with functional mobility including gait to short 
distances. The enrollee required varying assist with activities of daily living. There are no identifiable skilled 
nursing service needs. There are identifiable skilled therapy service needs, however they are not required on a 
daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for 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 pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility admission. 
 
You asked the Plan to pre-approve a skilled nursing facility admission. You say that the enrollee needs SNF 
care. The Plan denied your request. The Plan says the enrollee is receiving adequate and necessary intensive 
rehabilitation in the inpatient rehabilitation facility. 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 pre-approve a skilled nursing facility admission. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found there are identifiable 
skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily 
basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility 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 a skilled nursing facility admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a skilled nursing facility admission.