Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pay for continuous positive airway pressure (CPAP) supplies you received on August 23, 2021.  You asked the Plan to pay for the CPAP supplies. You say that this plan is your primary insurer, not your employer's plan. The Plan denied your request. The Plan says that they are not the primary payer- your other insurance is primary.  You must submit your claim to your other insurer first.  If they deny the claim, it will then be reviewed by the Plan for processing.  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  We agree that the Plan is the secondary insurer here under Medicare rules.  However, the Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan has failed to take any of the actions listed above that would meet their obligations regarding coordination of benefits.  The Plan has not sent the bill for these items to the primary insurer.  The Plan has not directed the provider to send the bill to the primary insurer.  The Plan has not made provisional payment for these items with the option of submitting the bill for reimbursement to the primary insurer.  The Plan has provided no documentation of any of these efforts that would have satisfied this burden. Therefore, we decided that the Plan has to pay for continuous positive airway pressure (CPAP) supplies you received on August 23, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for triamcinolone injections provided from May 4, 2021, to July 27, 2021.  You asked the Plan to waive the coinsurance for the injections. You say that you were not aware of any coinsurance for the injections. The Plan denied your request. The Plan says the correct coinsurance was applied.  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 20% coinsurance for Part B drugs, including chemotherapy drugs.     Procedure Allowed Amount 20% Coinsurance Therapeutic Injection (J3301) - May 4, 2021 $11.04 $2.21 Therapeutic Injection (J3301) - July 27, 2021 $10.32 $2.06 Total:  $4.27  You have been asked to pay $4.27, which is 20% of the allowed amount for the injections. The injections fall within the Medicare Part B Prescription Drugs 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 triamcinolone injections provided from May 4, 2021, to July 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an inpatient psychiatric admission.  You asked the Plan to pre-approve an inpatient psychiatric admission. The Plan denied your request. The Plan says that based on Medicare guidelines, the Mental Health Inpatient Psychiatric services you and/or your provider are requesting do not meet the requirements for approval beginning October 4, 2021.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient psychiatric admission.  Our reviewer says that an inpatient psychiatric admission is not medically necessary. Our physician reviewer found that based upon review the records provided it was not expected you would improve in a reasonable period of time for the dates in question as you did not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. You did not show any abnormal behaviors or any symptoms, which would require acute treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as you did not have dangerousness to self or others but was compliant with your treatment. The health Plan's denial of continued inpatient psychiatric services is appropriate. You did not appear to require inpatient mental health treatment beyond the date in question as you were not a danger to yourself or others, no auditory hallucinations or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve your condition or for the purpose of diagnosis beyond the date in question. I am unable to find an individualized treatment plan however it is alluded to in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission, you do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of October 4, 2021 forward as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were cooperative/compliant with treatment. You were not showing any aggressive behaviors, or any treatment required for acute threats of safety.  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 inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient psychiatric admission.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428GY) provided on May 7, 2021.  You asked the Plan to pay for ambulance service, advanced life support, emergency transport, level 1. The Plan denied your request. The Plan says the claim processed and denied correctly.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules say diagnosis code Z76.89 should be reported for patients who were transported by ambulance but did NOT require the services of an ambulance crew. Modifier GY should be appended.  We looked at the file and Medicare rules. The file shows that the ambulance transport was billed with diagnosis code Z76.89 (Persons encountering health services in other specified circumstances) and with modifier GY (item or service statutorily excluded or does not meet the definition of any Medicare benefit). Medicare says that diagnosis code Z76.89 does not support medical necessity and should be appended with a GY modifier Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428GY) provided on May 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is not met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.    We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 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 pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for intravenous infusions and does not have to waive the coinsurance for Medicare Part B drugs provided from August 6, 2021, to August 13, 2021.  You asked the Plan to waive the copayments for intravenous infusions and to waive the coinsurance for Medicare Part B drugs. You say that you were told that you would owe a minimal charge and these are not minimal charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $350 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.   You received intravenous infusions and Medicare Part B drugs on August 6, 2021, and August 13, 2021, at an outpatient hospital facility. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.   Date of Service Service Allowed Amount Amount You Owe 8/6/2021 Intravenous Infusion $185.26 $185.26 8/13/2021 Intravenous Infusion $185.26 $185.26 8/6/2021 Medicare Part B Drug $764.78 $152.96 8/13/2021 Medicare Part B Drug $764.78 $152.96  The total amount you owe is: $676.44.  You have been asked to pay the total amount of $676.44 for intravenous infusions and Medicare Part B drugs. Intravenous infusions fall within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 copayments for intravenous infusions and does not have to waive the coinsurance for Medicare Part B drugs provided from August 6, 2021, to August 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Life Alert system for the enrollee.  You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a Life Alert system for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home blood pressure monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this is only covered for patients on home dialysis.

The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. 

The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve a home blood pressure monitor.
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 your ability to not have these inserts is jeopardizing your job, as you are unable to walk properly. 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: 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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  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 based on the documentation provided the enrollee only requires short-term additional acute care services that can safely be administered at the current facility.   The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered 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.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency care provided on June 12, 2021.  You asked the Plan to waive the copayment for emergency care. You say that you are unhappy with the care you received. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $90 copayment for emergency care.   You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided on June 12, 2021.   Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  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 there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented acute rehabilitation nursing needs. While the enrollee may benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity 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 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office consultation and visits to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the office consultation and visits. You say that you want to see this physician regardless of the facility, and this physician is in-network at other locations. The Plan denied your request. The Plan says the provider is out-of-network. Please note, the Plan has authorized visits for this physician at the in-network location.  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. 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 the office consultation and visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for opioid treatment program services provided from January 24, 2021, to August 8, 2021.  You asked the Plan to waive the copayments for opioid treatment program services. You say that the services are necessary for your recovery but you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $35 copayment for opioid treatment program services.   The record shows that you received opioid treatment program services from January 24, 2021, to August 8, 2021, for a total of 11 visits. Therefore, you are responsible to pay a $35 copayment per each visit. The total amount you owe is: $35 (copayment) x 11 (opioid treatment program services) = $385.   You have been asked to pay the total copayment amount of $385 for opioid treatment program services. Opioid treatment program services fall within the opioid treatment program 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 copayments for opioid treatment program services provided from January 24, 2021, to August 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapeutic parenteral drugs, two or more administrations, different medications (D9612).  You asked the Plan to pay for therapeutic parenteral drugs. You say that this part of the surgery is necessary to fight infection and promote healthy healing. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefits.  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 therapeutic parenteral drugs, two or more administrations, different medications (D9612).