Persius/hicric huggingface dataset:
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 you need IRF care before you can go home safely. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your 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. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transtelephonic rhythm strip pacemaker evaluation (93293) rendered by the out-of-network (OON) provider on August 18, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the transtelephonic rhythm strip pacemaker evaluation (93293) rendered by the out-of-network (OON) provider on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-ray services provided on July 13, 2021, and August 31, 2021.  You asked the Plan to pay for the services provided. You say that a chiropractor is unable to perform manipulation without understanding where the misalignment is. The Plan denied your request. The Plan says x-rays are not a covered service.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. Services other than manual manipulation, when provided by a chiropractor, are not covered. Therefore, we decided that the Plan does not have to pay for the x-ray services provided on July 13, 2021, and August 31, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a SNF stay provided from July 1, 2021, to July 7, 2021.  You asked the Plan to waive the copayment for a SNF stay. You say that you are unhappy with the quality of care received and 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 $20 copayment for days 1-20 and a $60 copayment for days 21-44 for SNF care.    The record shows that you received a SNF stay from July 1, 2021, to July 7, 2021. Therefore, you are responsible to pay a $20 copayment for days 1-6 (July 1, 2021, to July 6, 2021). The total amount you owe is: $20 (copayment) x 6 (SNF days) = $120.   You have been asked to pay the total copayment amount of $120 for a SNF stay. A SNF stay falls within the SNF 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 SNF stay provided from July 1, 2021, to July 7, 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous device.  You asked the Plan to pre-approve Vertiflex Superion Interspinous device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 Vertiflex Superion Interspinous device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has lumbar spinal stenosis with neurogenic claudication. The Vertiflex 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 Vertiflex Superion Interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous device.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the colonoscopy services with bleeding control provided on August 24, 2021 billed with code 45382.  

You asked the Plan to pay for the billed code 45382. You say that it is felt these codes are all payable. The Plan denied your request. The Plan says 45382 is not payable when billed with 45385 unless a modifier is used.  

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, we have confirmed that the billed code 45382 is a column II code to column I code 45385. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the colonoscopy services with bleeding control provided on August 24, 2021 billed with code 45382.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Udenyca (Q5111).  You asked the Plan to pre-approve Udenyca. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested treatment have not been met.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Udenyca. Our reviewer says that the requested treatment is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has lung cancer and is receiving myelosuppressive chemotherapy with a 10-20% risk of febrile neutropenia. The enrollee does not have a significant risk, greater than 20%, of febrile neutropenia. The elements of the coverage criteria are not satisfied.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Udenyca have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Udenyca (Q5111).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location (R0070), the set-up of portable x-ray equipment (Q0092), and the x-ray exam of the foot (73630) rendered by the out-of-network (OON) provider on  December 18, 2020.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location (R0070), the set-up of portable x-ray equipment (Q0092), and the x-ray exam of the foot (73630) rendered by the out-of-network (OON) provider on December 18, 2020.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99213), destruction; first lesion (17000), and destruction; second through 14 lesion (17003) provided on May 12, 2021.  You asked the Plan to pay for the outpatient services. You say that the services provided were not related to the enrollee's hospice diagnosis. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.    Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the office visit (99213), destruction; first lesion (17000), and destruction; second through 14 lesion (17003) provided on May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (80307) provided October 5, 2020.  

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 code billed has a bundled relationship with another code 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 80307 is not supported in the medical record. Specifically, CPT 80307 shares a bundled relationship with code 80305 that was also billed. 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 (80307) provided October 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the implant maintenance procedures when prostheses are removed and reinserted (D6080) provided on June 16, 2021.  You asked the Plan to pay for the implant maintenance procedures. You say that there were no wrenches used to dismantle and reassemble the implants. You also say that the code charged to the insurance does not accurately reflect the services performed. The Plan denied your request. The Plan says this service is not a covered benefit 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 the implant maintenance procedures when prostheses are removed and reinserted (D6080) provided on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87541, 87581, 87631, 87640, 87798, U0004) provided on August 18, 2020.  You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87541, 87581, 87631, 87640, 87798, U0004) provided on August 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.  You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this device is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 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 assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that you do not 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 a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
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 IRF services are medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can receive the necessary services in 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. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve two hearing aids (V5298).  You asked the Plan to pre-approve hearing aids. You say that you have poor hearing in both ears and were told by your provider that you need hearing aids. The Plan denied your request. The Plan says the criteria for coverage of hearing aids are not met.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only for those who are pregnant or reside in a nursing facility.   We looked at the file and the Plan's rules. There is no indication that you are pregnant or currently living in a nursing facility. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve two hearing aids (V5298).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on August 4, 2021.  You asked the Plan to pay for the dental services. You say that the x-ray you received was not a special one of any kind. You say that you do not understand why it is not covered. You say that the dental office assured you that the dentist was in network. You also say that you have had x-rays like this before and they were covered. The Plan denied your request. The Plan says the limited oral evaluation is not listed as a covered service. The Plan says that periapical x-ray is not listed as a covered service either.  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 limited oral evaluation and periapical x-ray are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on August 4, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the laboratory work provided on July 9, 2021.  

You asked the Plan to pay for the laboratory. You say that the service was medically necessary. The Plan denied your request. The Plan says that no prior authorization was obtained.  

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 did not show if the referring physician was an in-network provider or an out-of-network provider. This means we cannot determine if the Plan's denial of the non-emergent service is supported. Therefore, we decided that the Plan has to pay for the laboratory work provided on July 9, 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a semi electric hospital bed.  

You asked the Plan to pre-approve a semi electric hospital bed. You say that you sleep on the sofa and do not get much rest therefore, you were hoping you could have a hospital bed. The Plan denied your request. The Plan says you do not meet criteria for the requested item.  

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:   

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or  

2. Requires attachments which can only be attached to a hospital bed; AND  

3. Requires frequent changes in body position and/or has an immediate need for a change in body position.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a semi electric hospital bed. Our reviewer says that the documentation does not support that you meet criteria for the requested item. Our physician reviewer found you have a medical history of prostate cancer, hypertension, human immunodeficiency virus infection and low back pain with difficulty ambulating. Based on the medical records provided there is no documentation that your condition requires position of the body in ways not feasible in an ordinary bed. The documentation does not support that you require frequent changes in body position or immediate changes in body position. Therefore, you do not meet criteria for the requested semi-electric hospital bed.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a semi electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi electric hospital bed.