Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve oncology breast MRNA testing.
You asked the Plan to pre-approve oncology breast MRNA testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the documentation does not support that the requested services are medically necessary.
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. The case file submitted to Maximus was largely incomplete. The case file was missing the following required documentation: the initial authorization request, the Plan's initial denial, Reconsideration request, the Plan's reconsideration determination, the 2020 H5926 Evidence of Coverage, the medical records used in making the Plan's decision. Without the required documentation, we are unable to properly review this case for medical necessity. Therefore, we decided that the Plan has to pre-approve oncology breast MRNA testing.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve30 additional routine transportation trips.You asked the Plan to pre-approveadditional routine transportation trips. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the request exceeds your benefit limit.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 30 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve30 additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 3, 2018.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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.
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 laboratory services provided on July 3, 2018.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management provided on April 28, 2020.
You asked the Plan to pay for the hospital discharge day management. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for hospital discharge day management provided on April 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee received enteral nutrition
and enteral and inhaled medications. The enrollee required moderate to maximal assistance with functional
mobility including walking to 50 feet with a rolling walker. The enrollee required varying assistance with
activities of daily living. The documentation does not support that the enrollee requires the specialized skills,
knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide
medically necessary and reasonable treatment. The documentation does not support that skilled nursing or
skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the
necessary services on an inpatient basis, at a SNF level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (62322) provided October 29, 2019.
You asked the Plan to pay for the injections. You say that these services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 62322 is Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance. We find that CPT code 62322 is not supported in the medical record. Specifically, the records provided do not document the procedure billed. The plan made multiple requests for additional documentation. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (62322) provided October 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP machine and supplies you received from March 19, 2020 to July 19, 2020.
You asked the Plan to waive the coinsurance for the CPAP machine and supplies. You say that you should not be responsible for these monthly charges. You say that you were told this would be covered in full. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment and related supplies. You have been asked to pay 20% coinsurance for the CPAP machine and supplies. The CPAP machine and supplies fall within the durable medical equipment and related 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 coinsurance for the CPAP machine and supplies you received from March 19, 2020 to July 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had on March 9, 2020.
You asked the Plan to waive the copayment for the office visit. You say that this was your annual yearly visit, so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that this was not your annual wellness exam. You are only entitled to one annual wellness exam every 12 months, and you had one on September 6, 2019 (only 6 months prior to this visit.) In addition, the medical records from this visit indicate that you were seen on this date of service in order to restart taking Gabapentin and to follow-up on your diabetes. That is why this is not an annual wellness visit and the copayment 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 $5 copayment for PCP office visits. You have been asked to pay a $5 copayment for the office visit. 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 office visit you had on March 9, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the endoscopic retrograde cholangiopancreatography (ERCP)
services coded 43274 provided on April 25, 2020.
You asked the Plan to pay for the endoscopic retrograde cholangiopancreatography (ERCP) services. You say
that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services
billed are not supported by the documentation.
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 43274 is endoscopic retrograde
cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct,
including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when
performed, each stent.
We find that CPT code 43274 is not supported in the medical record. Specifically, the documentation submitted
did not include a procedure note indicating the exact date of service. Based on this information, we decided that
Medicare rules for coverage of the endoscopic retrograde cholangiopancreatography (ERCP) services have not
been met. Therefore, we decided that the Plan does not have to pay for the endoscopic retrograde
cholangiopancreatography (ERCP) services coded 43274 provided on April 25, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 12, 2020.
You asked the Plan to pay for the physician service. You say that you received a bill for the services you received. The Plan denied your request. The Plan says during the enrollee's hospice election, fee-for-service Medicare covers attending physician services and all care unrelated to the terminal illness.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the office visit provided on June 12, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care provided from September 7, 2019, through September 11, 2019.
You asked the Plan to pay for hospital care. You say that the enrollee was not in hospice until September 12, 2019. You say that the claim was denied in error and payment should be provided. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on September 7, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital care provided from September 7, 2019, through September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable gas oxygen system (K0738) and oxygen
concentrator (E1390) provided on April 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for portable gas oxygen system and oxygen. You say that you were unaware the
provider was out-of-network. The Plan denied your request. The Plan says prior authorization must be obtained
for non-emergent services rendered by an out-of-network provider.
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 portable gas oxygen system (K0738) and
oxygen concentrator (E1390) provided on April 6, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you will have reached 100 days during your benefit period.
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 you will have received 100 days of SNF care during the benefit period from September 11, 2020, to December 20, 2020. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have 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 pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had on March 16, 2020.
You asked the Plan to waive the copayment for the specialty visit. You say that follow-up visits within 90 days of your surgery shouldn't have a copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $35 copayment for specialist visits. Records show that you had surgery on February 21, 2020. Although the visit at issue on March 16, 2020 is within 90 days of the surgery, this visit was performed by a different billing provider. Because these are different billing providers, the 90-day post-surgical period does not apply to follow up visits. You have been asked to pay a $35 copayment for the specialty visit. The specialty visit falls within the specialist visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the visit you had on March 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran X-ray provided on July 16, 2020.You asked the Plan to waive the copayment foran X-ray. You say that you disagree with the charges because you should not have to pay for additional X-rays.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 itsenrollees 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 $40 copayment for basic radiological services provided in a specialist's office. You have been asked to pay the allowed amount of $32.98, which is less than the $40 copayment for an X-ray. An X-ray 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 foran X-ray provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe new patient office or other outpatient visit (99201) provided on May 13, 2020, by an out of network (OON) provider.You asked the Plan to pay forthe new patient office or other outpatient visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has beencorrectly denied.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 forthe new patient office or other outpatient visit (99201) provided on May 13, 2020, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan (74176) provided on February 28, 2020.
You asked the Plan to pay for the CT scan. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says duplicate imaging reports were submitted for review. The plan states they have already paid for a claim for the same date of service, same enrollee, exact same CPT code, and same provider, which was already processed and paid.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met. In this case, there were no medical records provided confirming that two separate CT scans were given. The medical records provided are duplicates of one another, indicating that only one CT scan was provided on February 28, 2020. Therefore, we decided that the Plan does not have to pay for the CT scan (74176) provided on February 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveright/left power leg rest pad/calf adjustable footplate (K0108).You asked the Plan to pre-approveright/left power leg rest pad/calf adjustable footplate (K0108). You say that the requested right/left power leg rest pad/calf adjustable footplate (K0108) is medically necessary.ThePlan denied your request. The Plan says the requested right/left power leg rest pad/calf adjustable footplate (K0108) is 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 right/left power leg rest pad/calf adjustable footplate (K0108). Our reviewer says that the requested right/left power leg rest pad/calf adjustable footplate (K0108) is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the requested right/left power leg rest pad/calf adjustable footplate (K0108) is medically reasonable and necessary for the enrollee in this case. Based on the records provided, new power leg rests are not medically necessary as they are present on the enrollee's currentwheelchair.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of right/left power leg rest pad/calf adjustable footplate (K0108) have not been met.Therefore, we decided that the Plan does not have to pre-approveright/left power leg rest pad/calf adjustable footplate (K0108).