Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from March 18, 2021, to March 20, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you fainted the day after discharge and are unhappy with the care you received. 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 $260 copayment for days 1-7 for inpatient hospital care. You received inpatient hospital care from March 18, 2021, to March 20, 2021. Therefore, you are responsible to pay $260, which is less than the total copayment amount. You have been asked to pay a $260 copayment for inpatient hospital care. Inpatient hospital care 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 for inpatient hospital care provided from March 18, 2021, to March 20, 2021.
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit Maximus to make a decision on this type of complaint
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for telephone evaluation and management service (CPT code 99441-95)
provided to the enrollee on November 10, 2020.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says that the initial processing of this claim was correct, and documentation supplied did not support
adjustments.
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. there is no explanation from the Plan of what was denied or why. Therefore, we
decided that the Plan has to pay for telephone evaluation and management service (CPT code 99441-95)
provided to the enrollee on November 10, 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: 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 this is medically necessary. The Plan denied your
request. The Plan says there are no complex medical and intensive rehabilitation needs requiring supervision by
a rehabilitation physician and an intensive and coordinated interdisciplinary team in a resource intensive
inpatient hospital environment.
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 the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for gastrointestinal bleeding requiring surgery which was complicated by respiratory failure,
septic shock, and acute kidney injury. Medical problems are stable. There are no complex nursing or
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record
supports a need for physical and/or occupational therapy, there is no documented need for intensive
rehabilitation services. Medically necessary care can be provided in a different level of care. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that you are appealing because the last CT lung screen recommended to repeat in 6 months. The Plan denied your request. The Plan says the records show that the same study or a test like may have already been done. They do not show the results of that test. Further imaging cannot be approved without knowing the outcome of the test.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter. We reviewed the file and the Medicare rules. We find that an LDCT screening is performed on an annual basis.
The records show that a low dose CT was already performed on 3/30/2021. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete mandibular denture. You say that your previous dentures
broke, and you are not able to eat because they are broken. The Plan denied your request. The Plan says this
service is allowed one time every 60 months. The Plan also says that you have had this service less than 60
months ago.
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, complete mandibular denture (D5120)
is limited to one of either codes D5120 or D5140 once per 60 months. The record shows that you received a
complete mandibular denture (D5120) on January 9, 2020 and your complete mandibular denture (D5120)
benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete
mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an immediate mandibular partial denture (D5224).
You asked the Plan to pre-approve the immediate mandibular partial denture. You say that you only have one
functioning tooth on the upper portion of your mouth. The Plan denied your request. The Plan says this
procedure is not covered.
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-approve an
immediate mandibular partial denture (D5224).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft (D4263).
You asked the Plan to pre-approve the dental service. You say that part of the procedure was approved, and
part was not. You say that the part that was denied is necessary in your case. You say that the nerve in your
tooth is exposed. You also say that you are on a limited income, and this would be difficult for you to pay for.
The Plan denied your request. The Plan says bone replacement graft is not listed s 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 service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft (D4263).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from November 14,
2020 to November 27, 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 submitted records do not support the billing of DRG 871 and diagnosis code N17.0.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS
WITHOUT MV >96 HOURS WITH MCC) and diagnosis code N17.0 (acute kidney failure with tubular
necrosis). 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 these services. Our reviewer says
that the submitted records do not support the billing of DRG 871 and diagnosis code N17.0. Our physician
reviewer found the enrollee presented to the hospital with cough and fever and was diagnosed with acute
cystitis and sepsis. The documentation indicates a history of chronic kidney disease stage IV with a baseline
creatine of 2.3 to 2.7 and a baseline glomerular filtration rate (GFR) of 22 to 28. There is no evidence to
support an increase in creatinine three times baseline or a decrease in the GFR greater than 75 percent. The
DRG and diagnosis are not supported.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient hospital services rendered from November 14, 2020 to November 27, 2020..
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns for tooth #6 and #7.
You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says the services are
denied because the teeth do not appear to have significant breakdown.
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. The Plan covers the crowns
when the services are medically necessary and reasonable.
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 crowns. Our physician reviewer
found that tooth #6 has no discernable decay or destruction of tooth structure, and #7 has an existing restoration
that does not appear to be failing with no clear need for replacement. Our reviewer says that given the intact
status of tooth #6 and #7, there is not a need for crowns or associated buildups on either tooth.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not
have to pre-approve crowns for tooth #6 and #7.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested device. You say that the enrollee has a hard time remembering
to check her blood sugars. The Plan denied your request. The Plan says the criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin
with at least three daily injections or requires 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 the requested
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous
glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.

You asked the Plan to pre-approve a total electric hospital bed. You say that a total electric hospital bed is medically necessary. The Plan denied your request. The Plan says a total electric hospital bed is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy (CPT code 53854), for the enrollee.
You asked the Plan to pre-approve the service. You say that a further prostate procedure is indicated to open the enrollee's urinary channel. You state the enrollee prefers less-invasive option of Rezum at this time. The Plan denied your request. The Plan says the enrollee does not meet the criteria as the enrollee has had a prior prostate surgery.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Review of the file shows that the enrollee had a robotic prostatectomy December 2020. Therefore, the enrollee does not meet the criteria since they have had a prior prostate surgery. Therefore, we decided that the Plan does not have to pre-approve transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy (CPT code 53854), for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services to be rendered by the out-of-
network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render
the requested services.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve
chiropractic services to be rendered by the out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight 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 pre-approve inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. There is no need for inpatient hospital care post-surgery. The patient has stable cardiopulmonary and neuro function.
There are no acute medical or nursing needs and no IV medication needs. There are no peg or wound care needs or any ventilator needs. The patient can be safely managed in a skilled nursing facility or home based care. Inpatient care will amount to futile care and over treatment and will increase risk of complications. Our physician reviewer found that the enrollee's condition does not meet criteria for inpatient hospital services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the angiography services (75726 and 75774) provided on
April 29, 2021.
You asked the Plan to pay for the angiography services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says CPT codes 75726 and 75774 are inclusive
to 37244.
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 75726 is angiography, visceral, selective or
supraselective (with or without flush aortogram), radiological supervision and interpretation.
The CPT Code Manual definition of code 75774 is angiography, selective, each additional vessel studied after
basic examination, radiological supervision and interpretation (List separately in addition to code for primary
procedure).
We asked our coder 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 angiography services. Our reviewer says that CPT codes
75726 and 75774 do not meet criteria for billing or reimbursement consideration. Our reviewer found these
procedures would be inclusive to 37244, as a vascular emobilization or occlusion is inclusive to all all imaging
guidance to complete the intervention.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the angiography services have not been met. Therefore, we decided that the
Plan does not have to pay for the angiography services (75726 and 75774) provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve office visits to be rendered by the out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on May 21, 2020.
You asked the Plan to pay for the drug testing. 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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.
We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing provided on May 21, 2020.