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

We decided that the Plan does not have to pay more for the continuous positive airway pressure (C-Pap) device you received on August 6, 2020.
You asked the Plan to pay more for the C-Pap device. You say that you purchased a new C-Pap machine and reimbursement was denied. You are requesting payment of $640.80. The Plan denied your request. The Plan says it has reprocessed this claim and issued you reimbursement in the amount of $530.10 plus $.52 in interest. This payment was issued to you on August 24, 2021.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment. You have been asked to pay 20% coinsurance for the C-Pap device. The C-Pap device falls within the durable
medical equipment benefit category. The cost of this device was $640.81 according to your letter, so the Plan would be responsible for reimbursing you 80%of that amount (subtracting your coinsurance obligation.) You have been reimbursed $530.10 even though 80% of your purchase was only $512.64. So, at this point, you have actually been reimbursed more than 80% of the allowed amount. Therefore, we decided that the Plan does not have to pay more for the continuous positive airway pressure (C-Pap) device you received on August 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha syringe.

You asked the Plan to pre-approve Repatha syringe. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha syringe.

Benefits for Repatha syringe may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that based on the documentation provided, you do not have documented skilled nursing needs. In addition, you do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 1 physical therapy visit in your home, and 4 occupational therapy visits in your home.
You asked the Plan to pre-approve the home health services. You say that the visits are medically necessary. The Plan denied your request. The Plan says the requested visits are not medically reasonable or necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our reviewer says that the physical therapy and occupational therapy visits are not medically necessary. Our physician reviewer found the documentation does not support that you require additional skilled rehabilitation (rehab) services to provide treatment that is medically necessary. The reviewer found that you do not require skilled additional rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. The reviewer also found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The reviewer found that you or your caregivers should be independent with a home exercise program. Therefore, the reviewer found that the requested home health services are not medically necessary. 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 home health services have not been met. Specifically, the file does not support that you require additional skilled rehabilitation (rehab) services to provide treatment that is medically necessary. Therefore, we decided that the Plan does not have to pre-approve 1 physical therapy visit in your home, and 4 occupational therapy visits in your home.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from April 9, 2021, to April 10, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you went to the hospital and received no physical therapy or occupational therapy, but you are being charged $683.51. You say that this is not correct. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you are not being charged $683.51- you are only being charged the $325 copayment for the inpatient services.
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 $325 copayment per day for days 1-6 for inpatient hospital services.
You have been asked to pay a $325 copayment for the one day you recieved inpatient hospital services. This copayment applies regardless of the extent of services you receive while in the hospital. 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 services you received from April 9, 2021, to April 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gradient compression stockings (CPT code A6530).
You asked the Plan to pre-approve the compression stockings. You say that you are unable to afford the compression socks and are unable to afford them as you have low income. The Plan denied your request. The Plan says compression stockings are only covered for the treatment of open venous stasis ulcers.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve gradient compression stockings (CPT code A6530).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services (97810).
You asked the Plan to pre-approve acupuncture services. You say that this is the only treatment that helps your
leg nerve damage. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, coverage of acupuncture is only allowed for chronic
low back pain. This service is not being requested for this diagnosis. Therefore, we decided that the Plan does
not have to pre-approve acupuncture services (97810).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (procedure code G0483) provided to the
enrollee on January 19, 2021.
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 records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 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 drugspecific
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 must reflect the location of the patient when the specimen was obtained. The claim reflects a
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's
office (POS 11). 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 drug testing services (procedure
code G0483) provided to the enrollee on January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 13, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple code. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laser therapy treatment rendered on December 22, 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 services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee received laser therapy for the
treatment of lichen planopilaris. This can be treated with topical medication and orally with tablets. Low-level 
laser therapy is an emerging light therapy, although results are sometimes biased. While the services were not 
entirely cosmetic in nature, the records do not support that they were reasonable and medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laser therapy treatment rendered on December 22, 2020.  
 
Local Coverage Determination (LCD) L35163 and Local Coverage Article (LCA) A57475 referenced by the 
Plan is not valid for the services at issue and was not used in the MAXIMUS determination.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a topical application of fluoride varnish (D1206) provided on March 29, 2021.
You asked the Plan to pay for a topical application of fluoride varnish. You say that the requested service was a necessity for your care. The Plan denied your request. The Plan says the service at issue 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. 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 pay for a topical application of fluoride varnish (D1206) provided on March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a health club membership (S9970) provided on March 1, 2021, to May 1, 2021.
You asked the Plan to pay for a health club membership. You say that you have received payment for past claims that were submitted and would like payment for these claims as well. The Plan denied your request. The Plan says personal training sessions is not a covered service.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that the fitness benefit includes fitness facility membership or home-based programs, as well as web services and quarterly newsletters. You must use an in-network fitness facility and can select from their nationwide network of 17,000 locations.
The Plan's rules for coverage of gym benefits have not been met. The records show that personal training sessions are not a covered benefit. The EOC confirms that you must see a network provider and select from their nationwide network of 17,000 locations. Therefore, we decided that the Plan does not have to pay for a health club membership (S9970) provided on March 1, 2021, to May 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency transportation: wheelchair van (A0130) 
and unlisted ambulance service (A0999) provided June 3, 2021. 
 
You asked the Plan to pay for the non-emergency transportation and ambulance service. You say that the 
transportation allowed to you to see your surgeon and get a chest x-ray. The Plan denied your request. The Plan 
says the services are not covered because the provider does not participate with Medicare and you did not 
obtain prior authorization for the services. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
contract states that you can see any provider that accepts the plan and has not opted out of or been excluded or 
precluded from the Medicare Program.  
 
We looked at the file, and Medicare rules. The Plan verified that you did not obtain prior authorization for the 
transport. Additionally, they contacted the provider who confirmed that they do not participate with Medicare. 
Based on this information, we decided that Medicare rules for coverage of the non-emergency transportation 
and ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for the
non-emergency transportation: wheelchair van (A0130) and unlisted ambulance service (A0999) provided June 
3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for acupuncture services you received from May 14, 2021, to June 19, 2021.

You asked the Plan to waive the copayments for the acupuncture services. You say that before you started your treatment, you asked if there would be any copayment. You said that you were told there was no copayment for low back pain for acupuncture. You believe you were given incorrect information. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that phone records from May 6, 2021 show that you were told about the $30 copayment for acupuncture services.

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 $30 copayment for acupuncture visits.

You have been asked to pay a $30 copayment for the acupuncture services. 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 acupuncture services you received from May 14, 2021, to June 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found admission to an SNF is not reasonable and not necessary as you have no skilled nursing needs and does not need skilled therapies on a daily basis in an inpatient setting at the current functional level. You will not be able to make significant improvement in a predicted and reasonable period of time. Documentation does not support the need for an admission to an SNF. Your rehabilitation needs can be met at a lower intensity level. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve Vertiflex. You say that this procedure is not experimental/investigational
and there is literature to support its safety and effectiveness. The Plan denied your request. The Plan says the
denial of authorization for this service is correct, because Vertiflex is experimental/investigational.
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 Vertiflex. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device is experimental, more research is needed to show its 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas neoGen-series therapy (electrical cell stimulation), Vasopneumatic device therapy, and associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend provided on November 23, 2020.
You asked the Plan to pay for Sanexas neoGen-series therapy (electrical cell stimulation), Vasopneumatic device therapy, and associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend. The Plan denied your request. The Plan says the services do not meet the Medicare guidance criteria.
The Plan must follow Medicare rules. Medicare rules say The rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. You can find this information in Title 42 CFR Section 410.60. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Sanexas neoGen-series therapy (electrical cell stimulation), Vasopneumatic deice therapy, and associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend have not been met. Therefore, we decided that the Plan does not have to pay for Sanexas neoGen-series therapy (electrical cell stimulation),Vasopneumatic device therapy, and associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend provided on November 23, 2020.