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

We decided that the Plan does not have to waive the copayment for an MRI provided on May 4, 2020.

You asked the Plan to waive the copayment for an MRI. You say that you disagree with 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 $325 copayment for diagnostic radiology other than CT scans. 

You have been asked to pay the allowed amount of $235.79, which is less than the $325 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies 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 MRI provided on May 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you are near baseline function.
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 physician reviewer found that you were admitted to the acute hospital for neutropenia, sepsis, pneumonia, and respiratory failure. Your medical conditions are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee cannot tolerate 3 hours of intensive therapy daily.
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 physician reviewer found that the enrollee was admitted to the acute hospital for weakness and falls. He was treated for NSTEMI, congestive heart failure, and pneumonia. His medical conditions are stable. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that he will be able to fully participate in and benefit from the intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device (CPT Code(s): 22869).
You asked the Plan to pre-approve the device. You say that the service is necessary. The Plan denied your
request. The Plan says the service is considered experimental and investigational.
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 device. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the spinous process spacer device is experimental. More research is needed to show safety and
efficacy of the device.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex Superion device (CPT Code(s): 22869).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pay for acupuncture provided to the enrollee on August 7, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied this request. The Plan states Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that these services were not provided appropriately.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare offers limited coverage for acupuncture treatments for chronic low back pain meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. Based on the medical records provided, the acupuncture services are being provided for chronic neck pain but not for chronic lower back pain. Medicare only covers acupuncture services when provided for chronic lower back pain. The Plan does not cover acupuncture as a supplemental benefit. Therefore, we decided that the Plan does not have to pay for acupuncture provided to the enrollee on August 7, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan does not have to pre-approve re-approve proton beam therapy for the enrollee.
You asked the Plan to pre-approve proton beam therapy. You say that this treatment 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 LCD criteria.
Our Medical Director looked at the case file and the reopen request. Our Medical Director says that at issue is coverage for Proton beam therapy (PBT). The Maximus Physician Reviewer determined that proton therapy is an accepted approach for the treatment of prostate cancer, and that the Medicare coverage criteria were met in this case. The Plan requested a reopen and stated that while this treatment may be beneficial for the enrollee, the required Medicare coverage criteria were not met. The Plan states that there is no documentation by the provider supporting the advantage of PBT over Intensity Modulated Radiation Therapy (IMRT), and notes that the enrollee is not enrolled in a study, trial, or CED for evidence development. Our Medical Director states that the Plan is correct in this case. The enrollee is a 75-year-old man with a diagnosis of high-risk stage T1c adenocarcinoma of the prostate, Gleason score "4+4=8". The documentation is insufficient to demonstrate that all of the LCD coverage criteria for Proton beam radiation therapy have been met in this case. Medicare coverage criteria are 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 proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve re-approve radiation therapy for prostate adenocarcinoma (CPT Codes: 77295, 77300, 55876, G6002) proton beam therapy for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided the Plan does not have to pay for lab services provided to the enrollee on June 16, 2020 and billed under code 87631.
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 this type of screening is not covered by Medicare. We overturned the Plans denial. The Plan requested a reopen and stated that we did not apply the correct LCD criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not cover this assay for screening purposes. The medical records show this assay was done for screening purposes and its results would not have affected the outcome or treatment plan for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for provided to the enrollee on June 16, 2020 and billed under codes 87631.
Appeal type: Lab
Decision: Favorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on August 28, 2020.
You asked the Plan to pay for this service. You say that these lab services should be covered by the Plan. The Plan denied your request. The Plan says this type of screening request is not covered by Medicare. We overturned the Plans denial stating this lab service was ordered by a physician. The Plan requested a reopen and stated that this lab work was requested to establish baselines for new admission to a health care facility. Medicare only covers lab services for the purpose of diagnosing or detecting signs and/or symptoms of illness or disease. Medicare also does not cover services required by a third party. The Plan states the records indicate this testing was done for the purpose of admission to a facility which are classified as a screening and are not covered by Medicare.
The Plan follows Medicare rules. The rules explicitly say that screening tests are not covered. The rules state that lab services must be performed for the purpose of providing information regarding possible illness or disease. Lab services for the purposes of facility admission, employment, travel, or program participation are not covered by Medicare. 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 lab services provided to the enrollee on August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transurethral water vapor thermal therapy.
You asked the Plan to pre-approve transurethral water vapor thermal therapy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 transurethral water vapor thermal therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have benign prostatic hyperplasia (BPH) and lower urinary tract symptoms managed with tamsulosin. You are not having worsening symptoms. Pelvic ultrasound indicates a prostate size of 31 cc and post void residuals in the 400 cc range. The documentation does not support that a formal International Prostate Symptom Score questionnaire with score was performed. No uroflometry testing was reported. The documentation does not support reasoning why you are a poor candidate for other surgical interventions. Therefore, you do not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transurethral water vapor thermal therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve transurethral water vapor thermal therapy.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 22, 2020.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on August 22, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on August 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating free standing facility on September 22, 2020.
You asked the Plan to waive the copayment for lab work. You say that you do not agree with paying this 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 $20 copayment for outpatient diagnostic tests/lab services/freestanding laboratory. You have been asked to pay $11.35 which is less than a $20 copayment for lab work. Lab work falls within the outpatient diagnostic tests/lab services/freestanding laboratory 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 lab work provided by a participating free standing facility on September 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder arthroscopy (29823) provided on August 13,
2020.

You asked the Plan to pay for a shoulder arthroscopy. You say that this code is supported by the records. The
Plan denied your request. The Plan says this code is not documented.

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 29823 is arthroscopy, shoulder, surgical; debridement,
extensive, three or more discrete structures (e.g., humeral bone, humeral articular cartilage, glenoid bone,
glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the
rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]).

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 a shoulder arthroscopy. Our reviewer says
that this code is not supported. Our physician reviewer found CPT 29823 should be used only for extensive
debridement of soft or hard tissue. It includes a chondroplasty of the humeral head or glenoid and associated
osteophytes or multiple soft tissue structures that are debrided such as labrum, subscapularis and supraspinatus.
The operative report does not support extensive debridement.

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 shoulder arthroscopy have not been met. Therefore, we decided that the Plan
does not have to pay for a shoulder arthroscopy (29823) provided on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis (D1110), bitewing x-rays (D0274), and the panoramic x-ray (D0330) provided on October 23, 2020.
You asked the Plan to pay for the dental services. You say that you need this work done on your teeth. You say that you were advised that you would need a root canal. You say that because they took your plan and they were close by that it would be okay. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says the provider in this case was out of network on this date of service. The Plan also says that you must receive your care from a network provider.
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, dental services that you receive out of nework are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis (D1110), bitewing x-rays (D0274), and the panoramic x-ray (D0330) provided on October 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for weakness and a fall. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services (90792) provided on May 2, 2019.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service is not payable as the claim was submitted untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for this service was not filed until September 14, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services (90792) provided on May 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the lower level of care cannot provide a total interdisciplinary approach needed. The Plan denied your request. The Plan says the records do not support the need for an intensive rehab therapy program.
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 physician reviewer found that the enrollee was admitted to the acute hospital for respiratory failure, Covid-19, GI bleeding, and congestive heart failure. Her medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 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 acute inpatient rehabilitation facility (IRF) admission and services.
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. The Plan denied your request. The Plan says the
enrollee is receiving appropriate inpatient acute care, and does not require transfer.
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 physician
reviewer found that you were admitted to the current acute care hospital with respiratory failure and sepsis
related to ischemic colitis. You were treated with antibiotics. Recent notes suggest that you have no rectal
bleeding, have improvement in kidney function, and have the ability to breath room air comfortably. You
requires only short-term acute care services to help complete the required treatment in a hospital setting. You
do not require services at the LTACH that are not already available at the current facility. Therefore, this
request for LTACH services is not sufficiently supported and will be considered 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 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.