Persius/hicric huggingface dataset:
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Comprehensive Genomic Profile testing provided on
March 2, 2020.
You asked the Plan to pay for the Comprehensive Genomic Profile testing. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that the Comprehensive Genomic Profile testing is not supported in the medical record. Specifically,
this service should be coded with code 81479. In addition, the approved DEX Z code identifier should be
entered adjacent in the comment/narrative field. Based on this information, we decided that Medicare rules for
coverage of the Comprehensive Genomic Profile testing have not been met. Therefore, we decided that the
Plan does not have to pay for the Comprehensive Genomic Profile testing provided on March 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion Interspinous spacer (22869).
You asked the Plan to pre-approve a Superion Interspinous spacer. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 a Superion Interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy. 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 Superion Interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion Interspinous spacer (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the primary care visit you had on October 17, 2020, and the primary care visit and electrocardiogram (ECG) you had on December 7, 2019.
You asked the Plan to waive the cost sharing for the physician services and ECG. You say that you don't recognize these services and you don't think you went to the doctor on these dates. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that because the allowed amount for the ECG ($16.72) is less than your copayment responsibility, you are only responsible for $16.72 for the ECG in addition to the two primary care office visit copayments.
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 primary care services and a $20 copayment for non-radiological diagnostic services. Medical records from your provider clearly show that you were seen in your primary care doctor's office on both October 17, 2019, and December 7, 2019. In addition to the office visit, on December 7, 2020, you also received an ECG. You have been asked to pay a $5 copayment for each of these primary care office visits. In addition, you have been asked to pay up to a $20 copayment for the ECG. The ECG is considered a non-radiological diagnostic test. 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 sharing for the primary care visit you had on October 17, 2020, and the primary care visit and electrocardiogram (ECG) you had on December 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plandenied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as describedabove.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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but does not require an intensive inpatient rehabilitation therapy program. There is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this case.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on May 23, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that the hospital did not treat you on that date and that you had to return for care on May 24, 2020. 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 $90 copayment for emergency room visits. Medical records from May 23, 2020 show that the ER evaluated you for your cat bite. Your vitals were taken and you were provided medical guidance to continue on the medication prescribed to you by your doctor. You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the fact that you returned to the ER the following day because your symptoms worsened. 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 emergency room (ER) visit you had on May 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on June 12,
2020.
You asked the Plan to waive the copayment for ambulance services. You say that you were not informed that
you would owe such a high copayment for ambulance service and you cannot afford 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 $220
copayment for ambulance services.
You have been asked to pay a $220 copayment for ambulance services. Ambulance services fall within the
ambulance services 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 ambulance services
provided on June 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment fora CT scan of the abdomen (74170) performed.

You asked the Plan to waive the co payment fora CT scan of the abdomen. You say that you should not be held responsible for this charge because you have met your out-of-pocket maximum.The Plan denied your request. The Plan says the correct co payment was applied.

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 a $150 co payment for all diagnostic and nuclear medicine radiological services (excepting mammography and ultrasounds). 

In this case, the Plan has documented that you had not reached your out-of-pocket maximum. You have been asked to pay a $150 co payment for a CT scan of the abdomen. ACT scan of the abdomen 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 co payment fora CT scan of the abdomen (74170) performed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on April 2, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Specifically, medical records do not support a prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was performed. The information submitted does not confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on April 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment fora CT scan provided.

You asked the Plan to waive the co payment fora CT scan. You say that you were not informed that you would owe a co payment for advanced imaging.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 a $275 co payment for each advanced imaging service. 

You have been asked to pay the allowed amount of $199.02, which is less than the $275 co payment for a CT scan. A CT scan 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 co payment fora CT scan provided.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to provide a $120 reimbursement for the anti-reflective coating lens and
progressive lens (V2781, V2750) purchased on July 2, 2020.
You asked the Plan to provide a $120 reimbursement for the anti-reflective coating lens and progressive lens.
You say that you believe you should receive this reimbursement for the glasses you purchased. The Plan denied
your request. The Plan says that these claims submitted are not listed as standard routine eye wear and therefore
not eligible for the Plan's $120 reimbursement.
The rules say a health Plan must disclose to its enrollees in clear, accurate terms all cost sharing information
(such as copayments, deductibles and coinsurance). 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 a $120 reimbursement
for towards the purchase of eyeglasses or contact lenses.
We looked at the file and the Plan's rules. We did not see where the contract says the eyeglasses the enrollee
receives must be routine eye wear. The contract with the Plan does not define what the enrollee should expect
to be considered routine vision wear. The enrollee reasonable believed the eyeglasses they purchased would be
covered. Based on this information, we decided that the Plan's rules for coverage of the anti-reflective coating
lens and progressive lens have been met. Therefore, we decided that the Plan has to provide a $120
reimbursement for the anti-reflective coating lens and progressive lens (V2781, V2750) purchased on July 2,
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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea CT scan of the abdomen for the enrollee.You asked the Plan to pre-approvethe scan. You say that this is medically necessary.The Plan denied your request. The Plan says that the guidelines support advanced imaging if the ultrasound shows a liver nodule greater than 1 cm.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee shows signs of cirrhosis on the ultrasound of 4/3/20. The plan's position that CT is only recommended to evaluate liver lesions over 1 cm in diameter is problematic in some cases such as this one. The diagnosis of NASH and sonographic findings of cirrhosis mean the enrollee is at significant risk for HCC. While ultrasound is a useful screening tool there are some limitations of the technique especially in obese patients where ultrasound can be limited by body habitus. The enrolleehas had prior bariatric surgery, and currently has a BMI of 31.5. As such, subtle evidence of HCC may be masked due to inherent ultrasound limitations due to body habitus. Review of the records does not show MRI or CT with multiphase technique;thus,the requested CT is reasonable and should be approved.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 scan have been met.Therefore, we decided that the Plan has to pre-approvea CT scan of the abdomen for the enrollee.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 toopen the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care services coded 99308
provided on August 10, 2020.
You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 99308 is subsequent nursing facility care, per day, for the
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded
problem focused interval history; An expanded problem focused examination; Medical decision making of low
complexity. Counseling and/or coordination of care with other physicians, other qualified health care
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor
complication. Typically, 15 minutes are spent at the bedside and on the patient's facility floor or unit.
We find that CPT code 99308 is not supported in the medical record. Specifically, this service was billed with
diagnosis code F01.51 (Vascular dementia with behavioral disturbance). This diagnosis has a "use additional
code" instructional note listed in the ICD-10-CM manual. Based on this information, we decided that Medicare
rules for coverage of the subsequent nursing facility care services have not been met. Therefore, we decided
that the Plan does not have to pay for the subsequent nursing facility care services coded 99308 provided on
August 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on March 4, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot
be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. 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 the drug testing services provided on March 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital stay provided July 30, 2020 to July 31, 2020.You asked the Plan to waive thecopayment forthe inpatient hospital stay. You say that because of the state of the room, you did not get the best of care and should have stayed at the hospital longer but wanted to leave due to lack of cleanliness and quality of care.The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied per the Evidence of Coverage.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 $275 copayment per day for days 1 through 6 for Inpatient hospital care. You have been asked to pay $275 copayment for the inpatient hospital stay. The inpatient hospital stay falls within the Inpatient hospital care 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 forthe inpatient hospital stay provided July30, 2020 to July 31, 2020.Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review