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

We decided that the Plan does not have to pre-approve additional prosthetic leg accessories (L5973, L8417) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items exceed the enrollee's medical need, as the documentation does not fully support that this enrollee is a level 3 ambulator. There is documentation of use of a cane due to fatigue and a wheelchair when he is tired on long distances. Furthermore, the documentation notes that the enrollee was a successful right below knee prosthetic user for the past ten years. The documentation does not support that the enrollee now requires a microprocessor K5973 over a standard mechanical ankle. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional prosthetic leg accessories (L5973, L8417) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 

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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services daily. You do not meet 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient of efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this facility can provide you with the necessary 
therapy you need to recover in a safe and timely manner. The Plan denied your request. The Plan says the stay 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical management of pelvic fractures and non-surgical management of rib fractures after a fall. 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. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a resin-based composite filling (D2391) provided on June 1, 2021, by a non-participating provider.
You asked the Plan to pay for a tooth filling. You say that the dental fillings received were preventive in nature to prevent future decay and possible need for extraction and implants. The Plan denied your request. The Plan says you were not enrolled in the optional supplemental dental benefit at the time of service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Furthermore, the Plan confirms that you were not enrolled in the Optional Supplemental Plan for the date of service at issue. Therefore, we decided that the Plan does not have to pay for a resin-based composite filling (D2391) provided on June 1, 2021, by a non-participating provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you have stabilized medically and have been 
receiving skilled rehabilitation services in an inpatient rehabilitation facility (IRF). You no longer require daily 
skilled nursing and/or skilled therapy services. You could benefit from continued intermittent services at a 
lower level of care. Although you made slow progress with therapy, your functional improvement has 
plateaued, there is no indication that transfer to a skilled nursing facility is required. You can continue to 
receive skilled rehab services at the current IRF or be stepped down to a lower level of care. There are no 
services offered at a SNF that are not offered at an IRF. Admission to a SNF for inpatient skilled rehabilitation 
services is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the X-ray services (74022) provided on June 30, 2021.
You asked the Plan to waive the copayment for the X-ray services. You say that you were unaware these services would be considered outpatient. The Plan denied your request. The Plan says the copayment has processed correctly 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 a $110 copayment for Medicare-covered X-ray services. You have been asked to pay a total cost share of $104.41 for the X-ray services which is less than the required $110 copayment. This service falls within the Medicare-covered X-ray services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the X-ray services (74022) provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99214) provided April 16, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you did not receive services on the 
date in question. The Plan denied your request. The Plan says the copayment has processed correctly 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 a $35 
copayment for Medicare-covered visits with a specialist.  
 
You have been asked to pay a $35 copayment for the office visit. This service falls within the Medicare-
covered visits with a specialist benefit category. Medical records were submitted which support the services 
were received on the date in question. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit 
(99214) provided April 16, 2021.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to waive the cost for the wrist hand finger orthosis. We decided that the Plan does not have to waive the cost for the wrist hand finger orthosis.
You asked the Plan to waive the cost for the wrist hand finger orthosis. You say that you were told the copayment was $25 for each visit but you have been issued a bill for $300. You say that you don't understand why you were issued this bill. The Plan says that the $300 copayment applied correctly.
We decided that the Plan has to reduce the cost for the wrist hand finger orthosis.
The Plan says that you must pay the $300 outpatient hospital copayment for the orthosis. The orthosis is considered durable medical equipment and would only apply 20% coinsurance. The allowed amount of the orthosis is $396.33 (20% x $396.33 = $79.27). Therefore, we decided that the Plan has to reduce the cost for the wrist hand finger orthosis from $300 to $79.27.
We also decided that the Plan does not have to waive the cost for the wrist hand finger orthosis.
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% of the cost for Medicare-covered durable medical equipment. Therefore, we decided that the Plan does not have to waive the cost for the wrist hand finger orthosis.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for genetic testing services (claim 
202115200100237) you received from an out-of-network pathologist on January 8, 2021. 
 
You asked the Plan to reduce the coinsurance for the genetic testing services. You say that you were not aware 
that the pathologist and the ordering doctor were out-of-network. The Plan denied your request. The Plan says 
you were charged this coinsurance correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 40% 
coinsurance for out-of-network genetic testing.  

You have been asked to pay 40% coinsurance for the genetic testing services. Neither the pathologist nor the 
ordering doctor is in-network with your plan. 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 reduce the coinsurance for genetic 
testing services (claim 202115200100237) you received from an out-of-network pathologist on January 8, 
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an eyelid repair procedure (67908) 
provided on December 28, 2020. 
 
You asked the Plan to waive the cost-sharing for an eyelid repair procedure. You say that you would have had 
your surgery in 2021 if you had known that your deductible was not paid. The Plan denied your request. The 
Plan says the correct cost-sharing was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $245 deductible which applies to each Medicare-covered outpatient 
hospital facility or ambulatory surgical center visit. The contract also says that you must pay 10% coinsurance 
for each Medicare-covered outpatient hospital facility or ambulatory surgical center visit. 

The service you asked the Plan to waive the deductible for falls within the "Outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $245 deductible which applies 
to each Medicare-covered outpatient hospital facility or ambulatory surgical center visit. This cost sharing is a 
contractual obligation that had not been met at the time an eyelid repair procedure was received on December 
28, 2020. 
 
You have been asked to pay $275.49 for an eyelid repair procedure. Of this amount, $218.50 satisfied your 
deductible for 2020. The total Medicare-allowed charge for the procedure was $788.44. Subtracting the amount 
applied to the deductible, the remaining charge was $569.94. In addition to the deductible, you have been asked 
to pay coinsurance equaling $56.99, or 10% of the remaining charge, for a total of $275.49. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided 
that the Plan does not have to waive the cost-sharing for an eyelid repair procedure (67908) provided on 
December 28, 2020.  
 
Your complaint about not receiving prompt information about a reversed charge that affected your deductible 
for 2020 is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (procedure code 90832) provided to the enrollee on May 3, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there was no documented contact with the attending/primary care physician.
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 is "psychotherapy, 30 minutes with patient." We find that CPT code is not supported in the medical record. Specifically, the record shows that the services were provided by a Clinical Psychologist without consultation from the enrollee's Primary Care Physician. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy services (procedure code 90832) provided to the enrollee on May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for personal protective equipment (PPE) provided on June 1,
2021.
You asked the Plan to pay for PPE. You say that you do not agree with the denial. You also say that you were
unaware that you would be responsible for PPE, which has always been used even prior to Covid-19. The Plan
denied your request. The Plan says this service is not a covered expense 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 personal
protective equipment (PPE) provided on June 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiologic examination, spine, lumbosacral (72114) provided July 21, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you would like to dispute July 21, 2021 and July 30, 2021 billing due to too much negligence that went on The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $25 copayment for basic radiological services.
You have been asked to pay $25 copayment for the diagnostic service. The diagnostic service falls 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 radiologic examination, spine, lumbosacral (72114) provided July 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met at the current level of care with part B therapy services.
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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided September 1, 2019,
to September 22, 2019.
You asked the Plan to pay for the skilled nursing facility (SNF) services. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says that the provided does not support
coding of daily skilled therapy minutes as reported on the minimum data set assessment.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan's denial rationale is based on their auditor's finding that the number of
minutes of therapy received was not documented for the time period at issue. However, Maximus reviewed the
records and found numerous documents which specifically lay out the number of minutes provided by each
therapy discipline during the period. The Plan has not made a specific argument about which discipline is
misrepresented in the total minutes reported. The Plan also has not provided an in-depth review of the specific
dates where it is felt that the time documented is not supported. Because of the lack of specific argument,
Maximus is not able to verify whether the Plan's denial rationale has merit. As such, we find that the
adjustment to the billed skilled nursing facility services is not substantiated. Therefore, we decided that the
Plan has to pay for the skilled nursing facility (SNF) services provided September 1, 2019, to September 22,
2019.