Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a continuous glucose monitor system.

You asked the Plan to provide a continuous glucose monitor system. You say that the enrollee only has one
thumb to fingerstick test. The Plan denied your request. The Plan says criteria is not met for a CGM.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we
decided that Medicare rules for coverage of a continuous glucose monitor system have not been met.
Therefore, we decided that the Plan does not have to provide a continuous glucose monitor system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an OON
provider.
You asked the Plan to pre-approve durable medical equipment. You say that this is the only company that can
provide this specific equipment. The Plan denied your request. The Plan says these services can be provided in-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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
durable medical equipment to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 14, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation does not contain laboratory results.
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records are insufficient to determine whether the provided services were medically reasonable and necessary, as defined by Medicare rules, for the enrollee's needs. The elements of the coverage criteria are not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for rehabilitation services provided from February 17, 2021, to February 28, 2021.
You asked the Plan to waive the copayments for rehabilitation services. You say that you want to know why you are being charged. 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 $35 copayment for each rehabilitation therapy service. The record shows that you received rehabilitation services during a non-covered SNF stay from February 17, 2021, to February 28, 2021, for a total of 8 services. Therefore, you are responsible to pay a $35 copayment per each visit. The total amount you owe is: $35 (copayment) x 8 (rehabilitation services) = $280. You have been asked to pay the total copayment amount of $280 for rehabilitation services. Rehabilitation
services fall within the inpatient stay: covered services received in a hospital or SNF during a non-covered inpatient stay benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for rehabilitation services provided from February 17, 2021, to February 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Prolia injection provided on January 15, 2021.

You asked the Plan to waive the coinsurance for a Prolia injection. You say that you were pre-approved for the injection and were not notified that you owed anything. You state that you cannot afford the charges and will have to cancel future injections. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.

You received a Prolia injection on January 15, 2021. The total allowed amount is $1,227.05 and 20% of that is $255.41.

You have been asked to pay the total coinsurance amount of $255.41 for a Prolia injection. A Prolia injection falls within the Medicare Part B prescription drugs 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 a Prolia injection provided on January 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on January 15, 2021.
You asked the Plan to pay for ambulance service, advanced life support, emergency transport, level 1
(A0427, A0425). You say that the ambulance service was medically necessary. The Plan denied your request. The Plan says the ambulance transport was not medically necessary. The enrollee could have been safely transported by another type of motor vehicle, possibly a van transport vehicle.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425). Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found that the patient is an 89-year-old female who requested ambulance services for diarrhea for one week. Emergency Medical Services (EMS) arrived, and the enrollee was hemodynamically stable with normal vitals and she was in minimal distress. No difficulty breathing or
discomfort was reported. She was transported to the hospital without incident. The enrollee's presenting symptoms did not meet a prudent layperson's criteria for emergency care. The documentation does not support that other means of transport, such as a stretcher van, would be contraindicated. The documentation does not support that the enrollee required expertise, services, and special equipment in an ambulance. The documentation does not support that the ambulance transport to the hospital on January 15, 2021 was medically reasonable and necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, advanced life support, emergency transport, level 1
(A0427, A0425) have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on January 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479) provided on January 13, 2021.

You asked the Plan to pay for genetic testing. You say that this is a Medicare-covered service. The Plan denied your request. The Plan says this was not ordered by a physician that is treating the enrollee.

The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 

We looked at the file and Medicare rules. The records do not show that the testing at issue was ordered by the physician who is treating the beneficiary. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479) provided on January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (98940) provided December 1, 2020 to
December 4, 2020.

You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary and
should be covered. The Plan denied your request. The Plan says the physician does not participate in the
Medicare program.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for
chiropractic services (98940) provided December 1, 2020 to December 4, 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 are highly motivated and currently have home health visits that are not frequent. You state you were promised occupational therapy (OT) and were not given OT. You state you can meet your goal by receiving the proper skilled care. 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 in the Medicare rules section. 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You were admitted for a burst fracture of T12 after which you received care in a skilled nursing facility. You were discharged home in April 2021 and reports ongoing weakness. Medical conditions are stable. 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. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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. 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: Drugs
Decision: Favorable

We decided that the Plan has to pay for immunization administration of the flu vaccine provided on October 19, 2020.
You asked the Plan to pay for immunization administration (90471). You say that the Plan should pay this claim. The Plan denied your request. The Plan says that the Tdap vaccine is not covered by Medicare.
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 Plan denied the immunization administration of a Tdap vaccine, but the medical records show the enrollee received the flu vaccine. Therefore, we decided that the Plan has to pay for immunization administration of the flu vaccine provided on October 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 2, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 2, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 14, 2020, through November 17, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically necessary. The Plan denied your request. The Plan says that an inpatient admission is not medically necessary. The care delivered was consistent with an observation stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the enrollee was a then 69-year-old female who presented to the hospital Emergency Department (ED) on November 14, 2020 with reported chest and abdominal pain. The record shows that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from November 14, 2020, through November 17, 2020.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share charged for practitioner services and
supplies provided from November 23, 2020, to January 3, 2021.

You asked the Plan to waive or reduce this cost share. You say that you do not believe what is being charged is
correct. The Plan denied your request. The Plan says these copayments were charged based on the claim
submitted by your provider and the Plan contract agreement. Maximus partially overturned the Plans denial.
The Plan requested a reopen and stated that Maximus did not apply the correct contract language.

The Plan is correct in this case. 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 $50 copayment for specialist services.

You have been asked to pay the correct amount based on your contract with the Plan and the services and supplies that were provided to you at each visit. 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 or reduce the cost share charged for practitioner services and supplies provided from November 23, 2020, to January 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter, crutch substitute (E0118).
You asked the Plan to pre-approve a knee scooter. You say that due to the diagnosis listed and related symptoms, this is medically necessary for treatment. The Plan denied your request. The Plan says substitutes such as knee walkers have not been proven to be safe and effective.
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. Based on this information, we decided that Medicare rules for coverage f a knee scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter, crutch substitute (E0118).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided on March 10, 2021.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you were not informed that you would owe such a high copayment and would have denied the services if you had known. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug injection on March 10, 2021. The total allowed amount is $12,420.14 and 20% of that is $2,484.02. You have been asked to pay the total coinsurance amount of $2,484.02 for a Medicare Part B drug injection. A
Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug injection provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services rendered on February 1, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 64448 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services rendered on February 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous glucose monitor sensors.
You asked the Plan to pay for continuous glucose monitor sensors. You say that the enrollee has a history of
hypo/hyperglycemia which is the rationale for the CGM. The Plan denied your request. The Plan says criteria
for a CGM is not met therefore the supplies are not covered.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of continuous
glucose monitor sensors have not been met. Therefore, we decided that the Plan does not have to pay for continuous glucose monitor sensors.