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

We decided that the Plan does not have to waive the cost share forthe laboratory services provided on August 6, 2020.You asked the Plan to waive the cost share forthe laboratory services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received laboratory services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.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 per day, per provider, for Medicare-covered lab services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received laboratory services on August 6, 2020. You have been asked to pay a $20 copayment for the laboratory services. The laboratory services fall within the Outpatient diagnostic tests 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 cost share forthe laboratory services provided on August 6, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided on July 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the radiology services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 radiology services provided on July 7, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 6, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services 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 tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare
does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to
pay for the laboratory services provided on July 6, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan does not have to pre-approvea hydrogen breath test in the evaluation of small intestinal bacterial overgrowth.You asked the Plan to pre-approvea hydrogen breath test in the evaluation of small intestinal bacterial overgrowth. You say that this testing is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.The Plan is correct in this case. ThePlan must follow Medicare rules. Medicare rules say that this type of testing is not covered for diagnosing small bowel bacterial overgrowth.Our physician review states that the diagnosis was a history of bloating and loose stools and that you were undergoing evaluation of small intestinal bacterial overgrowth and irritable bowel syndrome.As this testing is not covered for your condition, Medicare coverage criteria were not met. Therefore, we decided that the Plan does not have to pre-approvea hydrogen breath test in the evaluation of small intestinal bacterial overgrowth.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint blocks for the enrollee.
You asked the Plan to pre-approve the blocks. You say that this is medically necessary. The Plan denied your request. The Plan says there is no pain from arthritis in the spine joints.
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 blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee is a 78 year old female with chronic low back pain. She received a medical branch block (MBB) on 3/18/2020 and reported less than 80% pain relief with no improvement in her ADLs. Her provider has requested facet joint injections. In this case, the documentation indicates that the enrollee did not receive at least 50% improvement in the ability to perform previously painful movements and activities of daily living (ADLs) from the previous injection. The review has determined that the enrollee did not meet the criteria for this request. 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 blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint blocks for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea porcelain crown (D2740), core build up (D2950 x 3), retainer crown (D6740 x 2), and a pontic (D6245).You asked the Plan to pre-approvethe dental services. You say that the services are medically necessary.The Plan denied your request. The Plan says a porcelain crown is not listed as a covered service. The Plan says core build up is not listed as a covered service. The Plan says retainer crowns are not listed as covered services. The Plan also says the pontic is not listed as a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea porcelain crown (D2740), core build up (D2950 x 3), retainer crown (D6740 x 2), and a pontic (D6245)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foreyewear frames (V2020) and lenses (V2202) purchased on September 23, 2020.You asked the Plan to pay foreyewear frames and lenses. You say that you should be reimbursed for this purchase.The Plan denied your request. The Plan says the maximum allowance for eyewear has been exceeded.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan provides an allowance for eyewear, if the eyewear you purchase costs more than $125, you pay the difference.
We looked at the file and the Plan's rules. The record shows that the eyewear you purchased totaled $299.98. The Plan has paid $125 and you are responsible for the remaining cost. Based on this information, we decided that the Plan's rules for coverage of eyewear frames and lenses have not been met.Therefore, we decided that the Plan does not have to pay foreyewear frames (V2020) and lenses (V2202) purchased on September 23, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services with CPT code 99285 provided on June 1, 2020.
You asked the Plan to pay for CPT code 99285. You say that the medical records support the billing of CPT code 99285 provided on June 1, 2020. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 99285 provided on June 1, 2020.
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect the services provided. In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the evaluation and management of a patient which requires three components (taking into account the urgency of the clinical condition or the patient's mental status): 1. a comprehensive history; 2. a comprehensive examination; and 3. medical decision making of high complexity. In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate significant threat to life or physiologic function. 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 CPT code 99285 Our reviewer says that the medical records do not support the billing of CPT code 99285 provided on June 1, 2020. Our reviewer found that the enrollee was seen in the Emergency Department (ED) on 6/1/2020 with a primary diagnosis of infection and inflammatory reaction due to internal fixation device of left ulna. The enrollee was seen on 6/1/2020 by an Emergency Room physician with a diagnosis of direct infection of right elbow; displaced fracture of olecranon process without intraarticular extension of right ulna; essential (primary) hypertension; and type 2 diabetes mellitus with hyperglycemia.
In this case the reviewed documentation has determined that the medical records did not support the billing of CPT code 99285. The documentation did not contain a complete comprehensive history. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 99285 have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room services with CPT code 99285 provided on June 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you require a higher level of care.The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of care.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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for COVID 19 pneumonia. Your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance, periodic oral evaluation,and dental x-rays provided on October 14, 2020.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the dental services provided are not covered under your contractual policy or by Medicare.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe periodontal maintenance, periodic oral evaluation, and dental x-rays provided on October 14, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the lack of care is affecting your health. The Plan
denied your request. The Plan says that your records show that it is not reasonable to expect that you need, or
can fully benefit from, the intensity of services 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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for pneumonia, respiratory failure,
and atrial fibrillation. Your medical conditions are stable. There are no medical needs requiring inpatient
admission. There are no complex nursing or rehabilitation needs. You do 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 you will be
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for practitioner visit. You say that your provider depends on the facility staff to verify eligibility and obtain the proper authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring facility is also out-of-network with 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 had network providers available who could have provided 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 July 27, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe replacement of lead wires with code A4557 provided on September 19, 2020.You asked the Plan to pay forthe lead wires. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says a TENS unit has been purchased in the previous 12 months.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 A4557 is Lead wires, (e.g., apnea monitor), per pair. We find that CPT code A4557 is not supported in the medical record. Specifically, the records show that lead wires were provided within the last 12 months. There are insufficient records to show that additional lead wires were medically reasonable and necessary for the enrollee's device. Based on this information, we decided that Medicare rules for coverage of the lead wires have not been met.Therefore, we decided that the Plan does not have to pay forthe replacement of lead wires with code A4557 provided on September 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe folding walker provided on September 20, 2020.You asked the Plan to waive the coinsurance forthe folding walker. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received a folding walker on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.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 10% coinsurance for Durable medical equipment. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a folding walker on September 20, 2020. You have been asked to pay a 10% coinsurance for the folding walker, totaling $9.90. The folding walker fallswithin the Durable medical equipment 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 forthe folding walker provided on September 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea low dose CT scan for lung cancer screening.You asked the Plan to pre-approvethe scan. You say that this is medically necessary.The Plan denied your request. The Plan says the records do not support that the enrollee is between 55 and 77 years of age.The Plan must follow Medicare rules. The rules say that a low dose CT scan is covered for enrollees between 55 and 77 years of age.The enrollee is 52 years old. Based on this information, we decided that Medicare rules for coverage of the scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea low dose CT scan for lung cancer screening
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard provided on July 29, 2020.
You asked the Plan to pay for the occlusal guard. You say that the device helps with grinding. The Plan denied your request. The Plan says the item 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. Although the Plan offers a dental benefit in excess of Medicare coverage, the occlusal guard is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal guard provided on July 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that the enrollee's ongoing medical care warrants this level of care.The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not require intensive physician or nursing supervision in an IRF. While the patient may benefit and participate in multiple therapies the patient's functional level does not require this therapy or appear to tolerate this therapy on an intensive rehabilitation therapy program providedin an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee