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

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the patient would be better served in a LTACH setting. The Plan denied your request. The Plan says the member is receiving appropriate inpatient acute care and does not require transfer to a LTACH.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found at the time of the request, the member's status is stable and improving. The member is tolerating trach collar trials during the day, with ongoing plans for more aggressive diuresis. There is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the knee orthosis you received on November 24, 2020.  You asked the Plan to waive the coinsurance for the knee orthosis. You say that this item was unnecessary and very expensive and you were not given an opportunity to refuse it. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for prosthetic devices and related supplies.     You have been asked to pay 20% coinsurance for the knee orthosis. The knee orthosis falls within the prosthetic devices and related supplies benefit category. This cost sharing applies regardless of whether or not the item was helpful. 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 knee orthosis you received on November 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on March 16, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The laboratory services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the partial upper denture with flexible base (D5225) provided on June 30, 2021.  You asked the Plan to pay for the dental service. You say that you were given the choice between a hard partial or a flexible partial. You say that you cannot tolerate a hard appliance as you have a small jaw, crowded teeth, and a problem with gagging with things in your mouth. You also say that this flexible denture is medically necessary. The Plan denied your request. The Plan says the partial upper denture with flexible base is not listed as 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 partial upper denture with flexible base is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial upper denture with flexible base (D5225) provided on June 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services (procedure code 97110) provided to the enrollee on June 23, 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 there is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code (G0157) for the billed service.  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 97110 is "Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility."  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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found a physical therapist assistant performed the services in a home setting. Therefore, there is a more appropriate code to use in this case for services performed in the home. The billed code is not supported by the documentation.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (procedure code 97110) provided to the enrollee on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for endodontic therapy (D3320), a prefabricated stainless-steel crown (D2931), and a diagnostic consultation (D9310) provided by an opt-out provider on April 23, 2021, and May 5, 2021.  You asked the Plan to pay for endodontic therapy, a prefabricated stainless-steel crown, and a diagnostic consultation. You say that this provider was not on the opt-out website. The Plan denied your request. The Plan says the provider is not a participating provider with Medicare.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. The opt out dates for the rendering dentist is August 7, 2018, to August 7, 2022.  Therefore, we decided that the Plan does not have to pay for endodontic therapy (D3320), a prefabricated stainless-steel crown (D2931), and a diagnostic consultation (D9310) provided by an opt-out provider on April 23, 2021, and May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the extremity study you had on June 17,
2021.
You asked the Plan to waive the copayment for the extremity study. You say that this should be covered by
your plan with no money due from you. The Plan denied your request. The Plan says you were charged this
copayment correctly. The Plan says that because the allowed amount for this service ($83.05) is less than your
copayment obligation, you are responsible for the full allowed 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 $125
copayment for radiological diagnostic services.
You have been asked to pay a $125 copayment for the extremity study. The extremity study falls within the
radiological diagnostic 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 the extremity study you had on June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on September 29, 2021.
You asked the Plan to pay for the eye refraction. You say that you were having trouble with your eyes and
needed another eye refraction done. This service was covered when you had it done earlier in the year, and you
say you feel it should be covered again. The Plan denied your request. The Plan says only one eye refraction
per year is covered by your vision benefit. You had a previous eye refraction on May 4, 2021, which was
covered at that time. Therefore, your benefit was exhausted on the date in question.
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 covers these services once per calendar year.
We looked at the file and the Plan's rules. You had a previous eye refraction less than one calendar year before
the date in question. Based on this information, we decided that the Plan's rules for coverage of the eye
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction
(92015) provided on September 29, 2021.
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 July 9, 2021, to July 21, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that your blood vessel was cut during surgery, so you don't think you should have to pay this copayment. 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 $275 copayment per day for days 1-6, and $0 for additional days for inpatient hospital services.    Records show that you were in the hospital for 12 days.  You were charged a $275 copayment per day for each of the first six days, for a total of $1650. This copayment applies regardless of the reason for your hospitalization. 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 July 9, 2021, to July 21, 2021.   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.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the forehead flap services coded 15731 provided on  You asked the Plan to pay for the forehead flap 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 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 15731 is forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap).  We find that CPT code 15731 is not supported in the medical record. Specifically, the documentation submitted did not include a procedure note that contains documentation for Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap); therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the forehead flap services have not been met. Therefore, we decided that the Plan does not have to pay for the forehead flap services coded 15731 provided on
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a respiratory virus screening panel (0202U) provided on November 10, 2020.  You asked the Plan to pay for a respiratory virus screening panel. You say that the enrollee came through the drive-through for this testing and did not see a doctor. The Plan denied your request. The Plan says this is not a covered screening service.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, a respiratory virus screening panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for a respiratory virus screening panel (0202U) provided on November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for medication assisted treatment, methadone, weekly bundle (G2067) provided on June 4, 2021 to July 30, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the medication assisted treatment. You say that you have been on medication assisted treatment for years. You would not transfer your insurance to an insurance provider that does not cover medication assisted treatment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for medication assisted treatment, methadone, weekly bundle (G2067) provided on June 4, 2021 to July 30, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that you would like the Plan to consider LTACH care for this patient.  You provided updated clinical notes to support this request. The Plan denied your request. The Plan says the enrollee can remain in the current acute care location until such time no further acute level care is needed.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99214) provided on August 6, 2021.  You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.  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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on August 6, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound guidance (76937) and venipuncture (36410)
provided on June 28, 2021.
You asked the Plan to pay for the ultrasound guidance and venipuncture. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted
documentation supports only one service on Page 6 Initial correspondence, which was previously paid.
The Plan must follow Medicare rules. Medicare rules say that 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.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the ultrasound guidance and venipuncture have not been met. Specifically, the record does not
show that these services were rendered more than once. The record also shows that a claim for these services
has already been processed and paid. Therefore, we decided that the Plan does not have to pay for the
ultrasound guidance (76937) and venipuncture (36410) provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for the refraction provided on June 8, 2021.  You asked the Plan to pay for the refraction. You say that you have a history of macular degeneration and the exam was necessary. You say that you were unaware you would need prior approval and did not know the Plan would not cover it. The Plan denied your request. The Plan says that the provider must bill the vision Plan for the refraction therefore, no adjustment will be made.  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 covers a refraction during a routine exam from a Plan vision care provider.  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the refraction have been met. Specifically, the refraction was received during an eye exam from a Plan vision care provider. Therefore, we decided that the refraction provided on June 8, 2021 must be paid.   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.