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

We decided that the Plan does not have to pay for the air ambulance service provided on August 16, 2019.You asked the Plan to pay for the air ambulance service. You say that the service was medically necessary.The Plan denied your request. The Plan says the enrollee was not transported to the nearest appropriate facility.The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. We looked at the file and Medicare rules. The transport was to the enrollee's requested facility not the closest appropriate facility. Based on this information, we decided that Medicare rules for coverage of the air ambulance service have not been met.Therefore, we decided that the Plan does not have to pay for the air ambulance service provided on August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on February 1, 2020.You asked the Plan to waive the copayment for urgently needed services. You say that you were told that the enrollee would only owe a $10 copayment.The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $10 copayment for urgently needed services provided by a primary care physician and a $40 copayment for urgently needed services provided by all other providers. The record shows that the enrollee received urgently needed services by a specialist on February 1, 2020. Therefore, the enrollee is responsible to pay the $40 copayment. The enrollee has been asked to pay a $40 copayment for urgently needed services. Urgently needed services falls within the urgently needed services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore,we decided that the Plan does not have to waive the copayment for urgently needed services provided on February 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 7, 2020 by an out of network (OON) provider.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 has network providers available who can provide the services 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 these services.Therefore, we decided that the Plan does not have to pay for the medical services provided on January 7, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on December 12, 2019. You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says the enrollee 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 services at 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 a domiciliary, rest home visit provided on December 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee. You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs this care to regain strength. The Plan denied your request. The Plan says that the services the enrollee needs could be provided in another setting. 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. The provided medical records indicate the patient is receiving appropriate services in the present acute care hospital. Continued care at this level is appropriate until the patient is stable to transfer to a lower level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for anesthesia services provided to the enrollee on August 27, 2019.
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request.
The Plan says that their time to review the case expired and therefore the case was forwarded to Maximus.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information
regarding their decision to deny your request. While it is understood the Plans timeframe for review expired,
the Plan is still expected to present a clear and valid case file to substantiate the denial. The case file presented
by the Plan is incomplete. Therefore, we decided that the Plan has to pay for anesthesia services provided to the
enrollee on August 27, 2019.
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: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve the additional upgrades/replacements described by code K0108. We decided that the Plan does not have to pre-approve the power seat elevation feature. You asked the Plan to pre-approve the additional upgrades/replacements described by code K0108. You say that these repairs and all requested items should be approved as medically necessary for the functioning of the power wheelchair. The Plan says that coding for a power tilt system (E1002), power recline system (E1003, E1004 and E1005), and tilt/recline system (E1006, E1007 and E1008) are all-inclusive. Usage of K0108 to bill for additional heavy duty or bariatric features is considered unbundling and is not allowed. We decided that the Plan has to pre-approve the additional upgrades/replacements described by code K0108. The Plan follows Medicare rules. Medicare rules say that K0108 is the appropriate code to describe miscellaneous options, accessories, and replacement parts which do not have a specific HCPCS code. The rules require the Plan to make reasonable and diligent efforts to gather and forward information regarding its denial. In this case, the Plan has not provided sufficient documentation to support that the items described by code K0108 on the authorization request are not covered by Medicare or are not medically necessary. The rule cited in the Plan's denial rationale does not appear to be applicable to the items being requested in this case as they are not being requested for additional heavy duty or bariatric features. Therefore, we decided that the Plan has to pre-approve the additional upgrades/replacements described by code K0108. Please note: This determination is limited only to approval of the provision of the features represented by code K0108. Some of these items may not be separately payable once billed if the items themselves are included payment for another code or have a specific HCPCS code available. We also decided that the Plan does not have to pre-approve the power seat elevation feature. The Plan follows Medicare rules. Medicare rules say that power seat elevation features are not covered as they do not meet the definition of durable medical equipment since they are not primarily medical in nature. Although the use of the seat elevator may be appropriate, neither Medicare nor the Plan provides coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation feature.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cone beam CTcapture and interpretation provided on February 10, 2020.You asked the Plan to pay forthe cone beam CT capture and interpretation. You say that you used an in network provider and had no knowledge that this visit would be other than a normal copay.The Plan denied your request. The Plan says this service is not a covered benefit.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 forthe cone beam CT capture and interpretation provided on February 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99232) provided on May 17, 2019 by an out of network (OON) provider.You asked the Plan to pay for the subsequent hospital care. You say that it is the hospital's responsibility to get authorization. This should cover for the hospital stay and automatically cover medical treatments. Please see medical records to prove necessity.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.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 subsequent hospital care (99232) provided on May 17, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an IRF admission and services. You asked the Plan to pre-approve IRF care. You say that admission to an IRF is necessary because the enrollee is unable to perform daily functions. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval of an IRF. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies; however, the enrollee's functional level does not indicate that this therapy must be in an IRF with an intensive level program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on December 19, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for genetic testing. You say that your facility doesn't accept walk-ins and you don't
have access to patient's demographics prior to date of service. The Plan denied your request. The Plan says no
prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
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 genetic testing provided on December 19, 2019 by
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a pneumatic compression device (E0652).
You asked the Plan to provide a pneumatic compression device. You say that your device results in improved symptoms and quality of life. The Plan denied your request. The Plan says the enrollee has not had a four-week trial of a basic device.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to provide a pneumatic compression device (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis, the lumbar-sacral
orthosis, and the knee orthosis and suspension sleeve provided on February 10, 2020.
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960), the lumbar-sacral orthosis
(L0650), and the knee orthosis (L1833) and suspension sleeve (L2397). You say that the Plan should pay this
claim. The Plan denied your request. The Plan says documentation submitted did not indicate the provider
discussed the need for the billed supply code, therefore the billed supply code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The medical record does not mention, or support medical necessity
for, the orthoses. Based on this information, we decided that Medicare rules for coverage of the shoulderelbow-
wrist-hand orthosis (L3960), the lumbar-sacral orthosis (L0650), and the knee orthosis (L1833) and
suspension sleeve (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis, the lumbar-sacral orthosis, and the knee orthosis and suspension sleeve
provided on February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fully-electric hospital bed for the enrollee.
You asked the Plan to pre-approve the bed. You say that due to the enrollee's condition, she needs a fully electric hospital bed with rails and a low air loss mattress. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a fully-electric hospital bed for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95937) provided on November 4, 2019.
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says it is inappropriate to bill the code for neuromuscular junction testing for Train of Four Monitoring.
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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. We find that CPT code 95937 is not supported in the record. Specifically, train of four monitoring does not meet the CPT definition of code 95937. It is inappropriate to bill the code for neuromuscular junction testing for train of four monitoring. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95937) provided on November 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services
provided on November 28, 2019.
You asked the Plan to pay for the inpatient EM services. You say that this is a separately payable service. The
Plan denied your request. The Plan says the provider at issue is noted to be a student which is not covered by
Medicare.
The Plan must follow Medicare rules. Medicare rules say that no payment may be made for services rendered
by students. The rules also state that, once licensed, students must update their taxonomy with the NPPES in
order to have their student taxonomy removed.
In this case, the rendering provider's NPI number is a student NPI. If the provider is now licensed, this must be
updated to reflect the new status. Without a valid, non-student taxonomy, payment cannot be made for these
services. Therefore, we decided that the Plan does not have to pay for the inpatient evaluation and management
(EM) services provided on November 28, 2019.
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 need a portable oxygen
concentrator so you have oxygen while outside of your house. The Plan denied your request. The Plan says
portable oxygen concentrators are not a covered item under Medicare.
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.
We looked at 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
You asked the Plan to pre-approve the compression stockings. You say that you require these stockings for venous insufficiency of your left leg. The Plan denied your request. The Plan says gradient compression stockings/wraps is non-covered for venous insufficiency without stasis ulcers, prevention of stasis ulcers, prevention of the reoccurrence of stasis ulcers that have healed, and treatment of lymphedema in the absence of ulcers.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545.