Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve comprehensive medical examination and evaluation
(92002) intermediate services, evaluation of a new or existing condition complicated with a new diagnostic or
management problem with initiation of a diagnostic and treatment program (92012).
You asked the Plan to pre-approve the vision services. You say that the appointment is for a post op and for
you to get the right glasses The Plan denied your request. The Plan says enrollee's must receive their vision
services from an in-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when the services are rendered by an in-network provider.
We looked at the file and the Plan's rules. The plan contract specifically says that medically necessary eye
exams require a referral from a plan physician to a plan specialist to diagnose and treat diseases of the eye
including glaucoma and cataracts. Based on this information, we decided that the Plan's rules for coverage of
the vision services have not been met. Therefore, we decided that the Plan does not have to pre-approve
comprehensive medical examination and evaluation (92002) intermediate services, evaluation of a new or
existing condition complicated with a new diagnostic or management problem with initiation of a diagnostic
and treatment program (92012).
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 does not meet criteria.
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 indication that you would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain your functional status. You can receive services at a lower level of 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
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery backup for continuous positive airway pressure (CPAP).
You asked the Plan to pre-approve a battery backup. You say that the enrollee resides where there are constant power outages and needs this item. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a battery backup for continuous positive airway pressure (CPAP).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fourteen (14) additional outpatient physical therapy 
(PT) sessions.

You asked the Plan to pre-approve the additional PT sessions. You say that the enrollee would benefit from 
finishing the current treatment plan. The Plan denied your request. The Plan says based on the clinical 
information received, it is felt that the enrollee is stable to continue rehabilitation with the home exercise 
program and follow-up with their physician. The Plan also says that there is nothing in the supplied 
documentation that supports that the services will be of such a level of complexity and sophistication, or the 
condition of the patient will be such that the services required can be safely and effectively performed only by a 
qualified therapist or under a therapist's supervision, versus a home exercise program after the total approved 
visits.

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 the additional PT sessions. 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 you have previously been treated with outpatient 
therapies and should be independent with a home exercise program. Our reviewer also found that there is no 
documentation of a recent injury or decline in function.

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 additional PT sessions have not been met. Therefore, we decided that the 
Plan does not have to pre-approve fourteen (14) additional outpatient physical therapy (PT) sessions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390).
You asked the Plan to pre-approve an oxygen concentrator. You say that you need this item for your second floor. The Plan denied your request. The Plan says you already have this item.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have an oxygen concentrator. The requested item serves the same purpose as an oxygen concentrator you currently have. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator (E1390).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 15, 2020.

You asked the Plan to pay for the ambulance services. You say that this should be paid as it was medically necessary. The Plan denied your request. The Plan says the enrollee is shown to have passed away prior to being loaded on the ambulance. Modifier -QL is needed for this situation.

The Plan must follow Medicare rules. Medicare rules say that when death occurs prior to being loaded onto an ambulance, providers must use modifier -QL to receive partial payment for the service.

The record shows that the enrollee passed away after dispatch but prior to being loaded onto the ambulance. The claim at issue was not billed with modifier -QL. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the influenza rapid diagnostic testing (87804) provided on April 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the diagnostic testing. You say that please reprocess the claim denied for not being part of the participating network. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 has network providers available who can provide 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 the influenza rapid diagnostic testing (87804) provided on April 6, 2020 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 neuromuscular stimulator (E0745) for the enrollee.
You asked the Plan to pre-approve this device. You say that this device is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for this device are not met.
The Plan must follow Medicare rules. The rules say that Medicare has specific coverage criteria for a neuromuscular stimulator (E0745). The medical records show the enrollee's condition appears to be secondary to neural compromise as noted by the physician notes. The medical records do not show the enrollee meets the coverage criteria as stated above. Therefore, we decided that the Plan does not have to pre-approve a neuromuscular stimulator (E0745) for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 23,
2020.
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like this claim
processed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible
for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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 dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 23,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes.
You asked the Plan to pre-approve diabetic shoes. You say that these are medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although diabetic shoes may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoride carriers (21089) and the health behavior intervention (96158) provided on August 18, 2020.
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says the fluoride carriers are dental in nature. The Plan says that fluoride carries and are not listed as a covered service. The Plan also says that health behavior intervention is not a covered service.
Medicare generally does not cover dental services. The Plan follows the same rule. Although the Plan offers a dental benefit in excess of Medicare coverage, the services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's 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 fluoride carriers (21089) and the health behavior intervention (96158) provided on August 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinary pathogen testing provided on February 5, 2021.

You asked the Plan to pay for the urinary pathogen testing. You say that this should be paid due to medical 
necessity. The Plan denied your request. The Plan says the POS code that was reported is not appropriate.

The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.

We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the 
lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that 
Medicare rules for coverage of the urinary pathogen testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the urinary pathogen testing provided on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve platelet-rich plasma injections.
You asked the Plan to pre-approve these services. You say that you have tried and failed oral analgesics and corticosteroid injections. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that platelet-rich plasma injections are covered when specific criteria are met. We looked at the file and Medicare rules. There is no submitted documentation to support that the criteria for coverage of the platelet-rich plasma injections have been met. The Plan made several attempts to obtain medical records from your physician; however, a response was not received. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve platelet-rich plasma injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that the item is medically necessary.
The Plan denied your request. The Plan says this is not a covered item.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the enrollee needs SNF care as she has dementia, and the therapy is helping her. The Plan denied your request. The Plan says the medical records submitted do not establish that the admission to the SNF is reasonable and 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 services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found based on the medical documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services are not shown to be required to establish a maintenance program 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. You say that the medication is necessary. The Plan denied your
request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 Retacrit. Our reviewer says that the
medication is medically necessary. Our physician reviewer found the Food and Drug Administration has stated
that the requested drug is indicated for the enrollee's condition. The elements of the coverage criteria are
satisfied. The requested service is recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Retacrit have been met. Therefore, we decided that the Plan has to pre-approve
Retacrit.
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 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 enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found 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. The enrollee was admitted for osteomyelitis and conversion of a below the knee amputation to an above the knee amputation. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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: Other
Decision: Unfavorable

We decided that the Plan does not have to hold you harmless for these services.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says this claim processed correctly. Maximus partially overturned the Plans
denial. The Plan requested a reopen and provided additional information regarding the provider. The Plan says
that Maximus stated the Plan must hold you harmless for any additional amount more than the $100 copayment
but does not have to reimburse you that copayment. The Plan states that it has been determined that this
provider is not a Medicare Provider and is from a non-Medicare company of affiliation. This means that this
provider is not eligible for Medicare payment.
This is a non-payable service as this is a non- Medicare provider. Therefore, no payment can be paid by the
Plan, and you are responsible for the entire cost of the service.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that no Medicare payment
may be made to a beneficiary for items or services provided directly by a provider who has opted out of the
program except or is not a Medicare eligible provider. It has been confirmed that these services were not
rendered by a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for tattoo
micropigmentation outpatient surgical procedure (11920) provided on November 7, 2020
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the cost-sharing charges for the shaving of a skin lesion provided on September 14, 2021.
You asked the Plan to reduce the cost-sharing charges for the shaving of a skin lesion. You say that you disagree with the outpatient surgery charges and would like the charges to be reduced to an office visit copayment. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that the $750 deductible does not apply to specialist visits. Your contract with the Plan also clearly says that you must pay a $35 copayment for specialist services, including surgery services. The record shows that you received the shaving on a skin lesion on September 24, 2021, by a specialist. The shaving on a skin lesion is considered an outpatient surgical procedure. Since services were rendered by a specialist, you are only responsible to pay the $35 copayment. The Plan says you must pay the deductible amount of $305.36 for the shaving of a skin lesion. Based on the Plan contract, however, you cannot be asked to pay more than a $35 copayment for the shaving of a skin lesion when provided by a specialist. Therefore, we decided that the Plan has to reduce the cost-sharing charges for the shaving of a skin lesion provided on September 14, 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.