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

We decided that the Plan does not have to pre-approvepanniculectomy.You asked the Plan to pre-approvethe services. You say that this is medically necessary.The Plan denied your request. The Plan says the notes do not show any of the covered indications.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 the services. Our reviewer says that the requested panniculectomy is not considered medically reasonable and necessary in this case. Our physician reviewer found as the enrollee's functional impairmentof chronic rashes/pain has not been documented to be refractory to usual standard medical therapy, the requested procedures do not satisfy Medicare medically necessary criteria. Her functional impairment has included chronic rashes; however, typical dermatologic management has not been documented.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 services have not been met.Therefore, we decided that the Plandoes not have to pre-approvepanniculectomy.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.You asked the Plan to pre-approveSNF care. You say that the SNF admission is medically necessary as the patient is not safe for discharge home as she does not have a full understanding of insulin measurement.The Plandenied your request. The Plan says the patient does not meet criteria for coverage of a SNF admission.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care isnot 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 SNF care. Our reviewer says that the enrollee does not meet criteria for coverage of a SNF admission. Our physician reviewer found the records do not support that the enrollee needs skilled nursing or skilled therapy on a daily basis. She is ambulating household distances and requires little assistance with mobility and transfers. While the enrollee may benefit from continuing physical and occupational therapy, she does not require theservices on 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 ofSNF care have not been met.Therefore, we decided that the Plan does not have to pre-approvean inpatient skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says the enrollee can receive the care required at the current facility they are in. Therefore, coverage criteria has not been met.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 is currently undergoing treatment at an acute care hospital (ACH) after a failed suicide attempt. The enrollee required an immediate emergency tracheotomy upon presentation. The enrollee has since been weaned from the ventilator. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says there was no documentation of a detailed order by the physician, and results for the billed date of service.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient level of care and percutaneous transcatheter
closure of the left atrial appendage (33340).
You asked the Plan to pre-approve inpatient level of care and percutaneous transcatheter closure of the left
atrial appendage. 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 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 inpatient level of care and percutaneous
transcatheter closure of the left atrial appendage. Our reviewer says that the requested items/services are not
considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific
clinical rationale for the requested inpatient level of care. The requested inpatient level of care services are not
medically reasonable and 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 inpatient level of care and percutaneous transcatheter closure of the left atrial
appendage have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient level
of care and percutaneous transcatheter closure of the left atrial appendage (33340).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fordiabetic shoes provided on October 16, 2019.You asked the Plan to waive the coinsurance forthe diabetic shoes. You say that you were told by the office that your insurance was going to pay 100% on your diabetic shoes.The Plan denied your request. The Plan says the claim was processed accordingly with your2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received diabetic shoes provided on October 16, 2019. You are asked to pay 20% coinsurance for the diabetic shoes. 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 coinsurance fordiabetic shoes provided on October 16, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 19, 2018 by an
out of network (OON) provider.
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 the services were 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 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. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on December 19,
2018 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 15, 2019 and July 24, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on July 15, 2019 and July 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that you need medical care for your wounds. The Plan denied your request. The Plan says you do not require daily skilled therapy or nursing services in an inpatient setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF services. Our physician reviewer found that at the time of discharge from the hospital, you did not require any skilled nursing or rehab services on a daily basis. You did not require skilled therapy to prevent deterioration with mobility or activities of daily living. You were medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your baseline. Therefore, an admission to a SNF for inpatient skilled rehab services is not 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit from August 13, 2019 to August 14, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you cannot afford the charges. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an ER visit. An ER visit falls within the emergency 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 an ER visit from August 13, 2019 to August 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora chest x-ray (71045) provided October 26, 2019. You asked the Plan to pay for the X-ray. You say that the claim is not a duplicate and should be paid.The Plan denied your request. The Plan says the correct modifier was not applied to note a second interpretation by another physician.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 CPT code 71045 is not supported in the medical record. Specifically the claim does not include the 77 modifier that would indicate an additional interpretation by a different physician. Based on this information, we decided that Medicare rules for coverage of the X-ray have not been met.Therefore, we decided that the Plan does not have to pay fora chest x-ray (71045) provided October 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 80050 provided on October 10, 2019.You asked the Plan to pay forCPT code 80050. You say that youwould like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says CPT code 80050 is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) isconsidered a non-covered code.You have requested payment for services billed under code 80050. Medicare does not cover or pay for services billed under this code.Therefore, we decided that the Plan does not have to pay forCPT code 80050 provided on October 10, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ER visits provided from August 30, 2019 to September 2, 2019.
You asked the Plan to waive the copayments for ER visits. You say that you cannot afford $50 copayments. 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 $50 copayment for emergency care. You had ER visits from August 30, 2019 to September 2, 2019. Therefore, you are responsible to pay the total copayment amount of $100.00. You have been asked to pay the total copayment amount of $100.00 for ER visits. ER visits fall within the emergency 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 copayments for ER visits provided from August 30, 2019 to September 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe removal of lens material provided on June 27, 2019.You asked the Plan to waive the copayment forthe removal of lens material. You say that the provider should be responsible for the charges.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 $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $295 copayment for the removal of lens material. The removal of lens material falls within the outpatient surgery and other medical 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 forthe removal of lens material provided on June 27, 2019.Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Urinary Tract Infection Panel rendered on May 14, 2019.
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 the testing is not covered.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that MolDX will reimburse approved tests. The test at issue was not approved through the MolDx program for the date of service at issue. Therefore, we decided that the Plan does not have to pay for the Urinary Tract Infection Panel rendered  on May 14, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe upper GI endoscopy provided on October 28, 2019.You asked the Plan to waive the copayment forthe upper GI endoscopy. You say that this was a diagnostic procedure and not a surgery. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $200 copayment for ambulatory surgical center and outpatient hospital visits. You have been asked to pay a $200 copayment for the upper GI endoscopy. The upper GI endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record showsthe upper GI endoscopy is considered a surgical procedure.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 forthe GI endoscopy provided on October 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from October 1,2018 through October 10, 2018.You asked the Plan to pay forinpatient hospital care. You say that the claim should be paid.The Plan denied your request. The Plan says the secondary diagnosis code is not supported by the records.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG. 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 inpatient hospital care. Our physician reviewer found the enrollee had a past medical history of Parkison's disease and dementia. He was admitted with mental status changes and found to have a urinary tract infection. The medical record does not document any history of exposure to toxins (for example solvents, drugs, radiation, paints, industrial chemicals, certain metals solvents, medications or drug ingestions other than as prescribes, radiation, paints, industrial chemicals, or certain metals). The medical records do not support the secondary diagnosis of G92 Toxic encephalopathy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate DRG G92 Toxic encephalopathy.Therefore, we decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from October 1, 2018 through October 10, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve2 retainer crowns (D6740) and 2 pontics (D6245).You asked the Plan to pre-approvethe dental services. The Plan denied your request. The Plan says retainer crowns and pontics are not listed as covered services.Medicare generally does not cover dental services. However, the Plan offers a dental benefitthat 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, retainer crowns and pontics are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve2 retainer crowns (D6740) and 2 pontics (D6245).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 7, 2019 to August 21, 2019 by an out of network (OON) provider.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 the services were 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 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. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on August 7, 2019 to August 21, 2019 by an out of network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered to the enrollee on May 13, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on May 13, 2019.