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

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 2, 2021, to August 6, 2021.  You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says you did not meet the rules for your hospital stay to be approved.  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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found you presented to the emergency department with general weakness and headache with an episode of vomiting. You were found to have altered level of consciousness (ALOC), severe hypoglycemia, severe hyperkalemia. Our reviewer found that hemodialysis was prescribed, and you were admitted. You improved with dialysis and did not have a severe infection or other acute condition which would require other treatments. Our physician reviewer also found that it was not expected that you would require hospital care that would likely cross 2 midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 2, 2021, to August 6, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90834) provided on June 15, 2021.  You asked the Plan to pay for psychotherapy services. You say that the requested services were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not clearly document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the tetanus vaccine rendered on July 1, 2021.  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 are not covered.    In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine rendered on July 1, 2021.   Benefits for these services 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: Other
Decision: Unfavorable

 We decided that the Plan does not have to pay for progressive and anti-reflective lens provided on  August 18, 2021.  You asked the Plan to pay for progressive and anti-reflective lens. The Plan denied your request. The Plan says covered eyeglasses after cataract surgery includes standard frames and lenses as defined by Medicare; any upgrades are not covered (including, but not limited to, deluxe frames, tinting, progressive lenses, or anti-reflective coating).   Medicare generally does not cover eyewear services. This rule does not apply to prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL.  The contract with the Plan does not cover any upgrades (including, but not limited to, deluxe frames, tinting, progressive lenses, or anti-reflective coating).  We looked at the file, the Medicare rules and the Plan's rules. The file shows that covered eyeglasses after cataract surgery includes standard frames and lenses as defined by Medicare; any upgrades are not covered (including, but not limited to, deluxe frames, tinting, progressive lenses, or anti-reflective coating). Therefore, we decided that the Plan does not have to pay for progressive and anti-reflective lens provided on  August 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.

You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 ten (10) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior extensive therapy for your condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve the SNF services. You say that you need and are ready for the next level of care at a SNF. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee does not need daily skilled services to be provided only on an inpatient basis in a SNF. The Plan says that the enrollee's needs can be met at a lower level of care.  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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, was treated for pain, and used oxygen via nasal cannula. The enrollee received physical therapy, speech therapy, and occupational therapy in the acute hospital. The enrollee was at supervision to contact guard assist level with functional mobility including gait to 200 feet. The enrollee required varying assist with activities of daily living. The enrollee tolerated a regular diet. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.  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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to an 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. The patient appears stable and improving but only requires short-term additional acute care services that can be safely administered at the current facility until lower level of care services are more appropriate. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit (99213) provided on
July 28, 2021.

You asked the Plan to waive the copayment for urgent care. You say that the services should be covered as you
saw a physician's assistant and not a specialist. The Plan denied your request. The Plan says the copayment
applied correctly based on the services rendered.

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 $45
copayment for Urgently needed services, specifically services that are provided to treat a non-emergency,
unforeseen medical illness, injury, or condition that requires immediate medical care.

You have been asked to pay a $45 copayment for an urgent care visit. The record shows that the PA is an
emergency medicine provider and not a primary care physician, which is why the copayment is not $10. 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 an urgent care visit (99213) provided on July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675).  You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery  disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Corus CAD testing rendered on June 26, 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 testing is not covered.  The Plan must follow Medicare rules. Medicare rules say that Corus CAD testing is covered when specific criteria are met.  We looked at the file and Medicare rules. The file shows that the enrollee had a history of obstructive coronary artery disease. 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 Corus CAD testing rendered on June 26, 2020.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health aide (HHA) services.  You asked the Plan to pre-approve the HHA services. You say that you would like this decision to be overturned because you are basically helpless in every way physically. The Plan denied your request. The Plan says the documentation indicates that your request is for a different certified home health agency, to fulfill your request for long term services in your home which is not covered by Medicare. The Plan also says that Medicare Criteria are not met as your request is for long term maintenance services.  The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.   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 HHA services. Our reviewer says that continual supervision, during the day or night, is custodial and not medically necessary, reasonable or coverable. Our physician reviewer found you are receiving home health skilled nursing services. This appears to be for the purpose of receiving regularly scheduled intravenous medication. Our reviewer found that there is no evidence that you are receiving home health therapy services. Our physician reviewer also found that while you certainly need assistance in completing activities of daily living, such assistance is intermittent.  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 HHA services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide (HHA) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a semi-electric hospital bed obtained out of network by the
enrollee on November 24, 2020.
You asked the Plan to pay for a semi-electric hospital bed obtained out of network. You say that this hospital
bed should be covered by the Plan. The Plan denied your request. The Plan says the provider is not in network.
Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information to
show the provider of this equipment is out of network and the enrollee did not have prior authorization for this
equipment.
The Plan is correct in this case. 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 Plan contract also states
durable medical equipment required prior authorization.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided this equipment. The Plan did not pre-approve this equipment. We found no exception
that would require the Plan to pay for this equipment. Therefore, we decided that the Plan does not have to pay
for a semi-electric hospital bed obtained out of network on November 24, 2020.
Therefore, we decided that the Plan does not have to pay for a semi-electric hospital bed obtained out of
network by the enrollee on November 24, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) provided on July 12, 2021.
You asked the Plan to pay for the oral hygiene instructions. You say that you feel you should not have to pay for this service. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
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 pay for the oral hygiene instructions (D1330) provided on July 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of the thoracic spine (72146), MRI of the cervical spine (72141), and MRI of the brain stem (70551) performed by an in-network provider on November 9, 2020, and November 10, 2020.

You asked the Plan to waive the copayment for MRIs of the upper spine. You say that you wanted all three diagnostic tests done on the same day but were told that was not possible. You say you expected to be charged for two copayments but were charged for three. You say you should only have to pay for two copayments The Plan denied your request. The Plan says the copayments were applied correctly. The Plan states you may have more than one cost share payment if you get more than one service at an appointment.

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 $110 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies. 

You have been asked to pay a total of $330 in copayments for MRIs of the upper spine ($110 copayment  3 MRIs = $330). MRIs fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of the thoracic spine (72146), MRI of the cervical spine (72141), and MRI of the brain stem (70551) performed by an in-network provider on November 9, 2020, and November 10, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (76700) provided August 18, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 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, we have confirmed that code 76700 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. 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 services (76700) provided August 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on July 7, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. 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 services (70450) provided on July 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (81408, 81407, 81406) provided June 23, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented cardiovascular disease.  We looked at the file and Medicare rules. The tests at issue are not covered under Medicare rules. 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 lab services (81408, 81407, 81406) provided June 23, 2021.