Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary. The Plan denied your request. The Plan says that rules for SNF care have not been met.
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 the requested SNF care is medically reasonable and necessary. Our physician reviewer found the enrollee is an 81 year old male who was admitted to an acute care hospital with a hip fracture. Despite the limited documentation provided, there is sufficient evidence that the enrollee does have skilled therapy needs. The enrollee requires strength and endurance training in a safe environment. A brief period of daily skilled services is reasonable to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for congestive heart failure and a sacral fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional OT visits.
You asked the Plan to pre-approve additional OT visits. You say that additional OT is medically necessary. The Plan denied your request. The Plan says additional OT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional OT visits. Our reviewer says
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. The provided records do not document why the now 13 approved occupational therapy visits have been inadequate to treat the enrollee's condition. After 13 occupational therapy visits, transition to a home exercise program appears appropriate at this point based on the available records. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional OT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) and extraction, erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140) provided September 17, 2020. 
 
You asked the Plan to pay for the dental consultation and tooth extraction. You say that it was necessary to 
have the tooth pulled. The Plan denied your request. The Plan says these services are not covered by your 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 the consultation - diagnostic service provided by 
dentist or physician other than requesting dentist or physician (D9310) and extraction, erupted tooth or exposed 
root (elevation and/or forceps removal) (D7140) provided September 17, 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 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services received on January 25, 2021 and April 5, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the medical services. You say that it was agreed upon that these services would be reimbursed. The Plan denied your request. The Plan says the services received are not supported by the documentation.

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. In addition, itemized statements of the services or medical records were not provided to the Plan to support the services received. Therefore, we decided that the Plan does not have to pay for the medical services received on January 25, 2021 and April 5, 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 periodic oral evaluation (D0120) and prophylaxis
(D1110) provided on February 9, 2021.

You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you would like to
appeal these services. The Plan denied your request. The Plan says at the time of these services you were not
enrolled in an active dental plan. The Plan also says that these dental services are not covered by the medical
plan.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation
(D0120) and prophylaxis (D1110) provided on February 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81225, 81223, 81226, 81227) provided June 29, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 81225, 81223, 81226, & 81227 is not supported in the medical record. Specifically, in this case a single panel was billed with multiple unbundled codes. 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 lab services (81225, 81223, 81226, 81227) provided June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the periodontal scaling and root 
planing - one to three teeth per quadrant (D4342) and localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue, per tooth (D4381) provided June 18, 2021. 
 
You asked the Plan to provide additional payment for the periodontal scaling and root planing and the localized 
delivery of antimicrobial agents. You say that you feel that it was not explained that the services were not 
covered prior to the services being rendered. The Plan denied your request. The Plan says the cost sharing was correctly applied to the periodontal scaling and root planing. Localized 
delivery of antimicrobial agents is not a covered service under your 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. The Plan covers the 
periodontal scaling and root planing and the localized delivery of antimicrobial agents when the services are 
medically necessary and reasonable.  
 
We looked at the file and Medicare rules. In this case you were charged your deductible plus 20% coinsurance 
for the periodontal scaling and root planing. Though the Plan provides dental benefits in excess of Medicare 
coverage, the localized delivery of antimicrobial agents is not a covered service. Therefore, we decided that the 
Plan does not have to provide additional payment for the periodontal scaling and root planing - one to three 
teeth per quadrant (D4342) and localized delivery of antimicrobial agents via a controlled release vehicle into 
diseased crevicular tissue, per tooth (D4381) provided June 18, 2021.
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 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 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. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites of two surfaces (D2392), resin-
based composites of three surfaces (D2393), crowns (D2740), and occlusal guard (D9945) provided from June 
28, 2021, to July 26, 2021. 
 
You asked the Plan to pay for the resin-based composites, crowns, and occlusal guard. You say that you cannot 
afford to pay for these services. The Plan denied your request. The Plan says you have maxed out your 
allowable benefit of $2,500 for the Plan year. 
 
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 Plan offers a $2,500 annual dental 
benefit maximum.  The contract says that after your annual maximum benefit maximum has been met, you are responsible for the 
full charges of any additional dental services. The record shows that you met the annual maximum benefit on 
June 16, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pay for the resin-based composites of two surfaces (D2392), resin-based composites of three 
surfaces (D2393), crowns (D2740), and occlusal guard (D9945) provided from June 28, 2021, to July 26, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Corus coronary artery disease (CAD) testing provided on August 6, 
2020. 
 
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the denial of payment for this testing is correct, because the 
manufacturer has failed to demonstrate that this testing resulted in improved patient outcomes or that testing 
changed physician management to result in improved patient outcomes. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
This testing was ordered by an in-network physician. The file does not show that the plan provided notice that 
genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved 
by the plan. Therefore, we decided that the Plan has to pay for Corus coronary artery disease (CAD) testing 
provided on August 6, 2020.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and preventive 
procedure (D1999) provided on June 24, 2021. 
 
You asked the Plan to pay for the first intraoral periapical x-ray and preventive procedure. You say that you 
were not made aware that this treating practice was no longer in-network. The Plan denied your request. The 
Plan says these services are not covered expenses under your dental plan. The Plan also says that you did not 
contact the Plan prior to this date of service to verify benefits and provider eligibility. 
 
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 the first 
intraoral periapical x-ray (D0220) and preventive procedure (D1999) provided on June 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a duplex scan provided on June 9, 2021. 
 
You asked the Plan to waive the coinsurance for duplex scan. You say that you were assured that this provider 
was in-network with the Plan. The Plan denied your request. The Plan says the cost-sharing amount you are 
being charged is correct. 
 
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 duplex scan. The allowed amount of this claim is $772.57, resulting in a 
coinsurance amount of $309.03. 
 
You have been asked to pay 40% coinsurance for duplex scan. Duplex scan 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 coinsurance for a duplex scan provided on June 9, 2021.  
 Your complaint regarding receiving inaccurate information about the network status of this provider is 
considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. 
Please contact the Plan for more information about your grievance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), 
intraoral - periapical each additional radiographic image (D0230) and limited oral evaluation - problem focused 
(D0140) provided June 22, 2021. 
 
You asked the Plan to pay for the intraoral x-rays and limited oral exam. You say that you were in pain and 
needed dental services to find out what was wrong. The Plan denied your request. The Plan says these services 
are not covered under your 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 the intraoral - periapical first radiographic image 
(D0220), intraoral - periapical each additional radiographic image (D0230) and limited oral evaluation - 
problem focused (D0140) provided June 22, 2021.  
 
Your complaint about which services are covered by the Plan under your benefits 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.