Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services provided on April 17, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate payment is made.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   In this case, the CPT Code Manual definition of code 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service. We find that CPT code 99053 is a bundled code. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. 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 medical services provided on April 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral complete series (D0210), and prophylaxis (D1110), provided on June 23, 2021.  You asked the Plan to pay for the comprehensive oral evaluation, intraoral complete series, and prophylaxis. You say that the services should be covered. The Plan denied your request. The Plan says you received care from an out-of-network provider.  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. Specifically, supplemental dental services are only covered when obtained by a participating provider. You received care from an out-of-network provider. This means that the services are not covered. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral complete series (D0210), and prophylaxis (D1110), provided on June 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on June 20, 2021.  You asked the Plan to pay for the CT scan. The Plan denied your request. The Plan says the service is bundled to another service billed on the same day.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  In this case, the CPT Code Manual definition of code 70450 is computed tomography, head or brain; without contrast material. We find that CPT code 70450 was billed with code 70496. CPT code 70450 may be eligible for payment when billed with this code pair. However, the claim does not show the service at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on June 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection services coded 64491 provided on January 14, 2021.  You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 64491 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded 64491 provided on January 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an injection of denosumab (a Medicare
Part B prescription drug) and injection administration service provided on March 22, 2021.
You asked the Plan to waive the cost-sharing for an injection (a Medicare Part B drug) and outpatient hosptial
facility services to facilitate the injection. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was charged based on the location of the services provided
and the Plan contract agreement. Maximus partially overturned the Plans denial. The Plan requested a reopen
and stated that Maximus did not apply the correct contract information.
The Plan is correct in this case. 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 Medicare Part B injections and a $325 copayment for
outpatient hospital services. The contract also states that enrollees have a responsibility to become familiar with
the contract and the services provided.
Your contract is prior notice that different service levels may have a specific cost share based on the place of
the service and the claim submitted by your provider. Keep in mind that the Plan contract cannot separately list
every service singularly.
The services provided were billed and coded as an injection provided by an outpatient hospital facility. You
have been asked to pay 20% coinsurance for a Medicare Part B injection. That injection was provided in an
outpatient hospital setting, which has a copayment of $325.
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 cost-sharing for an injection (a Medicare Part B drug) and
outpatient hospital facility services provided on March 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator obtained out of network on January
22, 2021.

You asked the Plan to pay for out of network equipment which is a non-standard brand oxygen concentrator.
You say that you had prior authorization for this equipment. The Plan denied your request. The Plan says you
did not have prior authorization to go out of network. Maximus overturned the Plans denial stating your Plan
physician wrote a prescription and referral for this equipment. The Plan requested a reopen and provided
additional information. The Plan stated it was confirmed with your physician that the prior authorization given
by the Plan was for an in-network provider for in network rental of standard oxygen equipment. The records
show you self-referred out of network for the non-standard oxygen concentrator obtained.

Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says
that durable medical equipment requires prior authorization. The records confirm that you were only given
prior authorization to obtain standard oxygen equipment from and in network provider.

You chose to go out of network and obtain a non-standard oxygen concentrator without prior authorization.
Therefore, we decided that the Plan does not have to pay for the oxygen concentrator obtained out of network
on January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (CPT code 99203) and CMT; extraspinal, 1 or more regions (CPT code 98943) provided on June 28, 2021, and July 28, 2021, by an out-of-network provider.  You asked the Plan to pay for the services. You say that the services are providing relief from pain that your neurosurgeon, rheumatologist, and neurologist have not been able to provide. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   You were approved for in-network coverage for an out of plan referral this provider for spinal manipulation relating to back and neck pain. The Plan approved this service to this non-network provider at this time due to the Emergency Declaration. Since this expired on September 30, 2021, you would need to have your provider refer you to a network provider for continued in-network coverage or re-submit a new request for out of network coverage to be re-reviewed. However, some items are not covered services with a chiropractor which included the following services: an office visit code (99203) performed on June 28, 2021, and chiropractic manipulative treatment (CMT) extraspinal code (98943) performed on July 21, 2021 and July 28, 2021. These are excluded services for chiropractic coverage under Medicare and therefore, not covered by the Plan. All other services that were performed and submitted on the claim did accurately apply your in-network benefits. Those codes were 98943-CMT spinal, and code 97110 which were therapeutic procedures. Therefore, we have upheld the payment for three services that are not covered services when performed by a chiropractor under Medicare rules in the amount of $186. Therefore, we decided that the Plan does not have to pay for the office visit (CPT code 99203) and CMT; extraspinal, 1 or more regions (CPT code 98943) provided on June 28, 2021, and July 28, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that , without IRF care, your quality of life and health will decline. You say that you need physical therapy, occupational therapy, and speech therapy to help live a comfortable and productive life. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed 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. Our physician reviewer found at the current medical stability and lack of medical complexity, there is no need for physical medicine and rehabilitation (PMR) 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 high 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. The enrollee needs physical therapy and occupational therapy in an alternate and low intensity level. While the enrollee may benefit from physical therapy and occupational therapy, his rehab needs can be safely met in an alternate and low intensity setting such as in-home with therapies. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the magnetic resonance imaging, abdomen (74181).  You asked the Plan to pre-approve the MRI. You say that the CT of the abdomen was completed but the imaging results did not show evidence of a hernia, therefore, the MRI of the liver was ordered. The Plan denied your request. The Plan says repeat imaging is not supported without results of prior imaging that show a clear reason for it.  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 the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the record indicates that the enrollee has a history of renal cysts, left inguinal hernia repair (07/21) and removal of abscess (unknown procedure/location). The record indicates that a CT scan has been performed but results are not provided. The requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time and the elements of the coverage criteria are not satisfied.  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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance imaging, abdomen (74181).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on May 4, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $60 copayment for consultation, diagnosis, and treatment by an out-of-network specialty care physician.    The enrollee has been asked to pay a $60 copayment for the out-of-network specialty care physician visit provided. The facility in this case is a non-plan provider and the claim was billed by the facility. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit (99214) provided on May 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.  You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says needs may be safely met in a skilled nursing facility.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for altered mental status, dehydration, and urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74176).  You asked the Plan to pre-approve a CT scan. You say that this is medically necessary. The Plan denied your request. The Plan says there is not documentation of other tests.  The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan. Our reviewer says that the requested CT scan is not medically necessary at this time. Our physician reviewer found the submitted records list vague "abdominal discomfort" of unspecified location as the indication for a CT scan. There are no laboratory data, ultrasound reports, or any red flags to warrant a CT scan.  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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74176).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Brovana (arformoterol).  You asked the Plan to pre-approve Brovana. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drug, Perforomist.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Brovana. Our reviewer says that Brovana is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the required drug, Perforomist. The reviewer found that there is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria has not been 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 Brovana have not been met. Specifically, the file does not show that the enrollee has tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve Brovana (arformoterol).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the surgical hernia laparoscopy (49650) provided on January 7, 2021.

You asked the Plan to pay for the surgical hernia laparoscopy. You say that you would like reconsideration because the primary surgeon and facility are in-network with the Plan. The Plan denied your request. The Plan says that the submitted claim includes a taxonomy which is not valid per the Medicare Taxonomy Crosswalk.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT code 49650 is supported in the record. Specifically, the Medicare Provider and Supplier Taxonomy Crosswalk clearly shows that this providers taxonomy code is valid and appropriate. Based on this information, we decided that Medicare rules for coverage of the surgical hernia laparoscopy have been met. Therefore, we decided that the Plan has to pay for the surgical hernia laparoscopy (49650) provided on January 7, 2021.

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 long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

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 you are stable and improving, but only require short-term acute care services that can be safely administered at the current facility until a lower level of care is appropriate. You do not require services at the LTACH that are not available at the current facility. 

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.