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

 We decided that the Plan does not have to waive the coinsurance for the inpatient services provided on June 15, 2021, through June 17, 2021.  You asked the Plan to waive the coinsurance for the inpatient services. You say that the services should be covered. The Plan denied your request. The Plan says the cost share was applied 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 10% per a stay for inpatient hospital care.      You have been asked to pay 10% per a stay for the inpatient services. This service 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 coinsurance for the inpatient services provided on June 15, 2021, through June 17, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral to an out-of-network psychologist.  You asked the Plan to pre-approve these services. You say that there are no in-network female providers. The Plan denied your request. The Plan says the services are available from network providers.  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. The Plan confirmed that they have in-network female psychologists available. 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 a referral to an out-of-network psychologist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomic testing services provided on April 30, 2021.

You asked the Plan to pay for the services provided. You say that the test has been proven to be a predictor of the enrollee's overall health outcomes success. The Plan denied your request. The Plan says the service is not covered.

The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing is not considered reasonable and necessary merely on the basis of a patient having a particular diagnosis.

We looked at the file, and Medicare rules. In this case, there are insufficient medical records from the enrollee's physician to show that the testing was ordered based on medical conditions, other medications, or past medical history. Testing for the purpose of medication selection offers a benefit over selection of medications based on contemporary evidence-based medication selection protocols. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomic testing services provided on April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 99140 and 99100 provided on
February 15, 2021.

You asked the Plan to pay for the anesthesia services. 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 separately payable.

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, we have confirmed that code the
anesthesia services is an add-on code and has not been billed with an appropriate primary procedure code.
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan
does not have to pay for the anesthesia services coded 99140 and 99100 provided on February 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain and shoulder.  You asked the Plan to pre-approve an MRI of the brain and shoulder. 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. Medicare rules say that MRIs 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 an MRI of the brain and shoulder. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no discussion concerning the rationale for MRI of the brain. There are no notes or plain films or detailed physical exam of either shoulder demonstrating the medical necessity of MRI of the shoulder.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the brain and shoulder have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain and shoulder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Trilogy home ventilator (E0466).  You asked the Plan to pre-approve a Trilogy home ventilator. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested item have not been met.  The Plan must follow Medicare rules. The rules say that the decision to use a ventilator or a BiPAP device is made based upon the specifics of each person's medical condition.  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 Trilogy home ventilator. Our reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found that the records do not include documentation of carbon dioxide (CO2) retention on an arterial blood gas done while the enrollee is awake and stable. There is no evidence that BiPAP has been tried, and failed, at home. Medicare does not cover a home ventilator when used as BiPAP.  Also, the enrollee was unable to meet minimum usage criteria when assessed in 2019; there are no more recent data on compliance. There are no recent clinical notes addressing the enrollee's need for nocturnal respiratory support.  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 Trilogy home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a Trilogy home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for a peripheral nerve block provided to the enrollee on March 2,
2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a peripheral nerve
block. The Maximus Physician Reviewer determined that the enrollee has tarsal tunnel syndrome, not trigger
points. The diagnosis was confirmed by physical exam. Based on the rules and records provided, the procedure
was medically reasonable and necessary to treat the enrollee's condition. The Plan requested a reopen and
stated the records showed no quantified estimation of benefit from prior injections. There was no described
dermatome or radicular pain pattern. There was no documented trial of activity modification, home exercises,
medication, physical therapy and spinal manipulation for six weeks or longer.
There is no significant decrease in range of motion, strength, or stability sufficient to interfere with daily
activity or having significant impact on school or job performance. There was no documented comprehensive
treatment plan with milestones and goals outlined. There was no documented absence of other serious
pathology.
The medical records show a single advanced practice registered nurse note dated March 2, 2021. The enrollee
is a 74-year-old man with pain and tingling in his foot and ankle which the enrollee reported interfered with
activities of daily living. The symptom severity was 9 out of 10. The duration of symptoms is not documented.
It is noted that conservative therapies had failed, but there is no indication of what those therapies were or how
long they were employed. The physical examination was notable for tenderness to palpation in between the
medial malleolus and the Achilles tendon. A diagnostic tarsal tunnel nerve block was performed.
Our Medical Director has concluded that the Plan is correct in this case. The documentation in the case file is
insufficient to demonstrate that the coverage criteria for a peripheral nerve block were met 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 these services have not been met. Therefore, we decided that the Plan does not
have to pay for a peripheral nerve block provided to the enrollee on March 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for inpatient admission for knee replacement.
You asked the Plan to provide coverage for inpatient admission for knee replacement.. You say that inpatient
admission is necessary for this knee replacement. The Plan denied your request. The Plan says Medicare
coverage criteria for inpatient care were not met. Maximus overturned the Plans denial. The Plan requested a
reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is the medical necessity of an
inpatient admission for a knee replacement procedure. The Maximus Physician Reviewer determined that there
is evidence of significant comorbidities that would relate to increased risks for post-operative complications
necessitating an inpatient stay. The Plan argues that the enrollee's medical history does not increase the
operative or perioperative risk. The medical records show you had a diagnosis of end-stage lateral compartment
arthritis of the right knee. You also had a history of hypertension, asthma, varicose veins, morbid obesity,
depression, restless legs syndrome, and severe degenerative disc disease.
Our Medical Director has concluded that the Plan is correct in this case. The clinical documentation does not
sufficiently demonstrate that the admitting physician reasonably expected that the necessary hospital care
would span at least two midnights. It is not documented that you had serious, uncontrolled medical conditions
that would require inpatient admission. Medicare coverage criteria were not met. 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 admission for knee replacement. have not been met. Therefore, we decided that the Plan does not
have to provide coverage for inpatient admission for knee replacement.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient admission provided to the enrollee from October 8,
2020, to October 22, 2020 as a separate admission event.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a hospital
readmission. The Maximus Physician Reviewer determined that the readmission was medically necessary. Our
physician reviewer found the enrollee was discharged when considered medically stable on October 22, 2020.
Our reviewer also found that the readmission did not result from a premature discharge from the same hospital.
The Plan argues that the non-participating hospital did not provide sufficient information to allow a reasonable
conclusion that the second admission was not preventable. The Plan states there is no documentation, other
than orders, on the preceding admission starting on September 14, 2020 available for review. Therefore,
completeness of care, stability at discharge, and adequacy of discharge planning could not be determined.
The medical records show the enrollee was at the time a 71-year-old woman with multiple medical problems,
including heart disease, diabetes, hypertension, and end-stage renal disease. The case file contains orders from
her admission to the non-participating hospital on September 14, 2020. The enrollee underwent coronary artery
bypass surgery and mitral valve replacement on September 14, 2020. The enrollee developed obstructive
jaundice and was found to have cholecystitis. A stent was placed. The enrollee was discharged on October 5,
2020. The enrollee presented back to the emergency department on October 8, 2020 with abdominal pain. The
enrollee was evaluated and admitted for treatment of sepsis from a presumed biliary source. The enrollee was
discharged when considered medically stable on October 22, 2020.
Our Medical Director has concluded the Plan is correct in this case. While the documentation supports that the
readmission to the hospital was medically necessary, there are insufficient medical records to determine
whether the readmission resulted from a premature discharge from the hospital. 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 inpatient
admission provided to the enrollee from October 8, 2020, to October 22, 2020 as a separate admission event
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the sleep study, unattended (95800) provided on May 21, 2021.  You asked the Plan to pay for the sleep study. You say that this sleep study was medically necessary. The Plan denied your request. The Plan says the criteria for coverage of this sleep study are not met. The Plan's review finds that the diagnosis of obstructive sleep apnea is not supported in the record and is not a valid diagnosis in this case.  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 sleep study. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee in this case has medical history of obstructive sleep apnea with report of dizziness. He used to have a BiPAP device but does not use it recently. The enrollee's records state that he had sleep apnea, but there was no provided objective evidence or signs and symptoms suggestive of such to support this diagnosis. The sleep study in this case is not supported. If the enrollee had sleep apnea, there was no indication that his apnea was worsening and failing previously prescribed treatment (BiPAP). And if he did not have apnea, there was insufficient description of signs and symptoms suggestive of a need for diagnostics for this condition. Medicare coverage criteria not met, and the sleep study will be considered not medically necessary at this time based on the provided documentation.   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 sleep study have not been met. Therefore, we decided that the Plan does not have to pay for the sleep study, unattended (95800) provided on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.  You asked the Plan to pre-approve this service. 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 service.  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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that the orthotics will help with stabilization since you need help stabilizing. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for observation care (99225) provided January 16, 2021.  You asked the Plan to pay for the observation care. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as 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.  We find that CPT code 99225 is not supported in the medical record. Specifically, observation care (CPT 99226) was already paid for this date of service. Based on this information, we decided that Medicare rules for coverage of the observation care have not been met. Therefore, we decided that the Plan does not have to pay for observation care (99225) provided January 16, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for anesthesia (01992) provided on September 28, 2020.  You asked the Plan to pay for anesthesia. You say that this was medically necessary. The Plan denied your request. The Plan says that there doesn't seem to be anything urgent or emergent about the members condition to warrant the use of an out-of-network provider for this procedure and the chosen anesthesia provider.  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 has stated that the use of an out-of-network provider is not supported. However, the Plan contract specifies that enrollees are not restricted to in-network providers. The Plan has not provided information to support any other denial reasoning. Therefore, we decided that the Plan has to pay for anesthesia (01992) provided on September 28, 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 for the enrollee.  You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from Acute Inpatient Rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says that the enrollee can safely receive the services he needs in other settings.  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.    The current medical need is to control blood sugars and lack of other medical complexity, there is no need for physical medicine and rehab physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee has no acute nursing care needs. Based upon the enrollee's current level of function, he does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical and occupational therapy, his rehab needs can be safely met when medically stable in an alternate and low intensity setting such as in a skilled nursing facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for 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 for the enrollee.