Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a telehealth visit for outpatient mental health care provided on September 9, 2021.  You asked the Plan to waive the copayment for a telehealth visit for outpatient mental health care. You say that you should not owe anything for a telehealth visit. 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 $30 copayment for each telehealth individual therapy visit for outpatient mental health care.   You have been asked to pay a $30 copayment for a telehealth visit for outpatient mental health care. A telehealth visit for outpatient mental health care falls within the outpatient mental health 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 a telehealth visit for outpatient mental health care provided on September 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650).  You asked the Plan to pre-approve the service. You say that your doctors are in agreement that the implantation of spinal neurostimulator electrodes is the best course of treatment at this time. You state you do not want to live on pills, and you have gone through physical therapy and the effects are very short term. The Plan denied your request. The Plan says your request is not medically necessary because your records fail to show the results of surgical and psychological consultation.  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 service. Our physician reviewer found you were noted to have previously undergone lumbar spine surgery. However, there was no indication provided that you had a further surgical consult to rule in the possibility of further surgery for treatment of her symptoms. In addition, there was no documentation provided for review from a psychological evaluation. For these reasons the criteria for coverage would not have 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a physician office service provided on September 28, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the physician office service. You say that an incorrect diagnosis was submitted with the original claim. The Plan denied your request. The Plan says there was no referral from the enrollee's primary care physician to the non-participating provider. Therefore, services were denied.  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 a physician office service provided on September 28, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0481) provided on June 22, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for drug testing. You say that this sample was sent to us to test, and we have performed the test at the request of the ordering physician. You also say this test is deemed medically necessary for the treatment and management of this patient. The Plan denied your request. The Plan says this service was ordered by a non-participating provider and the Plan had network providers available to perform the services at issue in the appeal.

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 (G0481) provided on June 22, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group one power operated vehicle (POV) (K0800).  You asked the Plan to pre-approve the POV. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.          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 POV. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation does not reveal a detailed neuromuscular exam or gait evaluation and the previous physician wellness visit states the patient can do light physical activity, housework without help, grocery shop without help, drive a car, has not needed assist for dressing, bathing, eating, or getting around the house. While the patient may have the cognition to safely operate the power scooter, the documentation does not support that the POV will significantly improve the patient's ability to participate in MRADLs in the home.  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 POV have not been met. Therefore, we decided that the Plan does not have to pre-approve a group one power operated vehicle (POV) (K0800).
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for anesthesia services (00813) provided on July 19, 2021.  You asked the Plan to pay for anesthesia services. You say that you do not understand why this was denied. The Plan denied your request. The Plan says that this was not billed with an appropriate modifier.  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 stated that the service at issue was not reported with a required modifier. However, the Plan did not include a claim form or other documentation showing how this service was billed in the submitted case file. Without this information, the Plan's denial cannot be verified. Therefore, we decided that the Plan has to pay for anesthesia services (00813) provided on July 19, 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 pay for an office visit provided on August 9, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that services were provided to the enrollee so payment should not be denied. The Plan denied your request. The Plan says services were rendered by a non-participating provider which was also the referring provider with no prior authorization. Therefore, payment was denied.  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 an office visit provided on August 9, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) provided August 31, 2021.  You asked the Plan to pay for the complete upper denture. You say that this service was pre-approved and should be covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers the complete upper denture once every five years.   We looked at the file and Medicare rules. The Plan provided documentation showing that an immediate upper denture was previously covered on February 19, 2021. The predetermination notice shows that an approval for a complete upper denture was valid from January 29, 2021, to April 29, 2021. The denied service was performed on August 31, 2021. Based on this information, we decided that the Plan's rules for coverage of the complete upper denture have not been met. Therefore, we decided that the Plan does not have to pay for the complete denture - maxillary (D5110) provided August 31, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from March 23, 2021, to March 25, 2021.  You asked the Plan to pay for the services. You say that the claim should be reconsidered. The Plan denied your request. The Plan says that the DRG was not correctly reported in this case.  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 has not substantiated their denial as they have provided no information to determine which DRG was correct to use in this case. It appears that the provider sent medical records by the plan, but the plan did not send these records to Maximus for review. Therefore, we decided that the Plan has to pay for inpatient hospital services provided to the enrollee from March 23, 2021, to March 25, 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 these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer.  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. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for behavioral health telehealth services provided by an in-network provider from May 25, 2021, to September 27, 2021.  You asked the Plan to waive the copayments for the behavioral health telehealth services. You say that you would like the copayments waived because the services took place over the phone. The Plan denied your request. The Plan says the originally denied services on September 13, 2021, and September 27, 2021, have been reprocessed to pay with $40 copayments, and you have been asked to pay 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 $40 copayment for each Medicare-covered individual or group visit. Cost sharing for virtual services a $40 copayment for telehealth visits.  You have been asked to pay a $40 copayment for each of the behavioral health telehealth services. ($40 x 7 visits = $280). The behavioral health telehealth services fall within the "Outpatient mental health 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 copayments for behavioral health telehealth services provided by an in-network provider from May 25, 2021, to September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on October 27, 2020.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.  The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.   We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 11. However, the records do not show that the specimen was collected in an office setting. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on October 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).  You asked the Plan to pre-approve the service. You say that the Vertiflex is an approved procedure under Medicare. The Plan denied your request. The Plan says the Medicare criteria for reasonable and necessary are not met as it has not been shown to be safe and effective in long term studies and there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold standard of decompression.  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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed         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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab testing (87426) provided September 1, 2021.  You asked the Plan to pay for the lab testing. You say that the test was medically necessary and should be covered. The Plan denied your request. The Plan says this test was performed for travel purposes and not for medical reasons. This service is not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, COVID-19 testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab testing (87426) provided September 1, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency care provided on September 19, 2021.  You asked the Plan to waive the copayment for emergency care. You say that you disagree with 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 $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 September 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home health (HH) skilled nursing (SN) services (CPT code G0299 x4).

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says records show that nine (9) nursing visits have previously been approved to help you. The Plan states your vital signs, taken by the home health nurse, are stable. The Plan states there have been no recent changes to your treatment plan or your medications. and your medical condition has not changed recently. The Plan states your records do not support the need for a skilled nurse to make more visits.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 physician reviewer found the health plan's denial should be upheld. You do not have documented skilled nursing needs. As such, the ongoing, requested, HH SN services are not medically necessary or reasonable. 

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 the home health (HH) skilled nursing (SN) services (CPT code G0299 x4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC).  You asked the Plan to pre-approve these services. You say that the enrollee has difficulty getting around. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.   Records show that these services is being requested for use in a SNF. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC).
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 IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested IRF care have not been met.

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 that the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.

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.