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 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 enrollee's medical needs are being met in the current acute setting.
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 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 he 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions from an oral surgeon.
You asked the Plan to pre-approve dental extractions from an oral surgeon. You say that the extractions need to be completed by an oral surgeon because your general dentist cannot do them. You say that you are in pain and need the extractions done as soon as possible. The Plan denied your request. The Plan says the services being requested are not covered under the enrollee's contract.
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, this benefit is limited to services performed by a participating general dentist. The services being requested are through a non-participating oral surgeon. Therefore, we decided that the Plan does not have to pre-approve dental extractions from an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous glucose monitor (CGM). 
 
You asked the Plan to pay for the CGM. You say that the claim should be paid. The Plan denied your request. 
The Plan says the documentation does not discuss the need for the billed services for treatment of the enrollee's 
condition. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical 
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the 
type and quantity of items ordered and for the frequency of use.  
 
The record shows that documentation submitted did not indicate the provider discussed the need for the billed 
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to 
pay for continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical/thoracic injection.

You asked the Plan to pre-approve a cervical/thoracic injection. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 a cervical/thoracic injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's condition. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 

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 cervical/thoracic injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical/thoracic injection.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound guidance for needle placement provided on February 23, 2021, billed with code 76942-26.
You asked the Plan to pay for the ultrasound guidance. You say that the provider is entitled to payment for this procedure. The Plan denied your request. The Plan says payment is bundled with payment for the Column 1 code.
The Plan must follow Medicare rules. Medicare rules say that when a Column 1/Column 2 edit exists between a code pair, only the Column 1 code is payable unless the edit has a modifier indicator of 1, and a clinically appropriate modifier is used.
In this case, 76942 is a Column 2 code in relation to the billed code 36556. This code pair has a modifier indicator of 1; however, no clinically appropriate modifier was reported to support bypassing the edit. Modifier -26 is not an NCCI modifier. Therefore, we decided that the Plan does not have to pay for the ultrasound guidance for needle placement provided on February 23, 2021, billed with code 76942-26.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services provided on March 12, 2021.
You asked the Plan to pay for the services provided. You say that the documentation supports the billed services. The Plan denied your request. The Plan says the billed code cannot be verified.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not indicate the amount of time spent with the enrollee. 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 critical care services provided on March 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for 94 units of the infusion supplies represented by code A4222
provided from July 31, 2020, to September 11, 2020.
You asked the Plan to pay for 94 units of the infusion supplies. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not
support the unit of services billed for code A4222.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units
provided for each procedure code.
We find that 94 units of CPT code A4222 are not supported in the medical record. The medical record provided
is unclear regarding how many units of CPT code A4222 was provided. Based on this information, we decided
that Medicare rules for coverage of 94 units of the infusion supplies have not been met. Therefore, we decided
that the Plan does not have to pay for 94 units of the infusion supplies represented by code A4222 provided
from July 31, 2020, to September 11, 2020.
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 this is the level of care you require. The Plan denied
your request. The Plan says that your care needs could be met with either admission to a skilled nursing facility
or with home health.
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
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care.
You were admitted for C2-T2 laminectomy and fusion. Your medical problems are stable. There are no
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
Our physician reviewer found that your 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
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive hereditary cardiovascular screening (81405,
81403, 81404, 81401) provided on December 31, 2020.
You asked the Plan to pay for a comprehensive hereditary cardiovascular screening. You say that this was
medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
(CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients.
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not
covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive hereditary
cardiovascular screening have not been met. Therefore, we decided that the Plan does not have to pay for a
comprehensive hereditary cardiovascular screening (81405, 81403, 81404, 81401) provided on December 31,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pump for water circulation pad (E0236) and a pad for water circulation heat unit (for replacement only) (E0249).

You asked the Plan to pay for the heating pad replacement supplies. You say that the heating pad should be covered because it is required as part of your therapy. The Plan denied your request. The Plan says the services are not covered under the member's contract under any normal circumstances.

The Plan must follow Medicare rules. Medicare rules say that heating pads and their replacement parts are not covered as they are not reasonable or necessary. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of heating pad replacement supplies have not been met. Therefore, we decided that the Plan does not have to pay for a pump for water circulation pad (E0236) and a pad for water circulation heat unit (for replacement only) (E0249).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient visit (99204) provided on May 15, 2021.
You asked the Plan to pay for the outpatient visit. You say that you would like reconsideration because this service was billed with the appropriate place of service code. The Plan denied your request. The Plan says payment is not allowed for these services because the evaluation and management service was billed with an incorrect place of 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 99204 is office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
We find that CPT code 99204 is not supported in the record. Specifically, this claim was billed with an outpatient visit CPT code and emergency department place of service code. Except in specific circumstances which are not indicated in this record, it is not appropriate to bill emergency department services with an office or outpatient CPT code. Based on this information, we decided that Medicare rules for coverage of the outpatient visit have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient visit (99204) provided on May 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) rendered on
April 7, 2021.

You asked the Plan to waive the copayment for these services. You say that you were charged for a routine
annual visit. The Plan denied your request. The Plan says the copayment 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 a $100
copayment for other Medicare-covered diagnostic procedures and tests.

Review of the file shows that you received an EKG on April 7, 2021. Per the contract with the Plan, there is a
$100 copayment for other Medicare-covered diagnostic procedures and tests. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these
services was $14.80. Given that the allowed amount was less than the $100 copayment, you have been asked to
pay $14.80 for these services.

The amount you are being asked to pay is not for the office visit but for the EKG. Therefore, we decided that
the Plan does not have to waive the copayment for the electrocardiogram (EKG) rendered on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a health club membership (S9970) for the 2020 benefit allowance.
You asked the Plan to reimburse you for a health club membership. You say that due to the pandemic, you were unable to get the wellness form in on time. You also say that 2020 was difficult and stressful due to the pandemic and the health club was closed due to lockdown and then reopened in June 2020. You are asking if an exception can be made for reimbursement. The Plan denied your request. The Plan says reimbursement was received after the deadline date.
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 plan reimburses you up to $300 each calendar year towards your cost for membership in a qualified health club or fitness facility. Reimbursement requests must be received by the Plan by no later than March 31st of the following year. The Plan's rules for coverage of gym benefits have not been met. The EOC confirms that reimbursement requests must be received no later than March 31st of the following year. Please note, the Plan had a 30-day extension from the March 31st deadline for Coronavirus circumstances. The records show that you submitted a reimbursement form on June 3, 2021. Therefore, we decided that the Plan does not have to reimburse you for a health club membership (S9970) for the 2020 benefit allowance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the outpatient surgery services provided from May 6, 2021, to May 20, 2021.
You asked the Plan to waive the cost shares for the services provided. You say that you never had a copayment when having these services. The Plan denied your request. The Plan says the claim processed 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 $250 copay for outpatient surgery at a hospital facility. The file shows that you received surgery services at an outpatient hospital facility on May 6, 13, and 21, 2021. You were charged a $138.47 copay for each date of service. Because the amount is less than the $250 copay, you were charged the lesser amount. The services fall within the outpatient surgery 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 cost shares for the outpatient surgery services provided from May 6, 2021, to May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided on April 26, 2021.
You asked the Plan to waive the copayment for inpatient hospital services. You say that the day after you had surgery you had complications, and the providers advised you to go back to the hospital. You also say you feel the copayment should be waived because this service is a result from a surgery that went wrong. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $300 copayment each time you are admitted to an acute care hospital.
You have been asked to pay a $300 copayment for inpatient hospital services. Inpatient hospital services fall 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 copayment for inpatient hospital services provided on April 26, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not primarily medical in nature. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the minimally invasive lumbar decompression (MILD) 
procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is supported by Level 1 clinical evidence. 
The Plan denied your request. The Plan says this is only covered as part of a clinical study. 
 
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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is experimental. More research is needed to show safety and efficacy of the 
MILD procedure. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the minimally invasive lumbar decompression (MILD) procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on April 21, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for drug testing. You say that you are appealing with supporting documentation. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 drug testing provided on April 21, 2021 by an out-of-network (OON) provider.