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

We decided that the Plan does not have to pay for anesthesia for shoulder surgery provided on February 25, 2021.
You asked the Plan to pay for the anesthesia. The Plan denied your request. The Plan says the billed service cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 01630 is anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for anesthesia. Our reviewer says that this does not meet criteria for reimbursement consideration. Our reviewer found the documentation does not include a detailed report of anesthesia care during a surgical procedure. Therefore, this procedure cannot be confirmed as performed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for shoulder surgery provided on February 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to
insufficient evidence of efficacy.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this device is experimental. More research is needed to show safety and efficacy of the device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on July 6, 2021.
You asked the Plan to waive the copayment for emergency care. You say that you waited over an hour and a half to be
seen and eventually left and went to an urgent care facility instead. 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 July 6, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is not medically necessary. The Plan denied your request. The Plan says the enrollee has declined additional treatment.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 21, 2021 by an out-of-network provider.
You asked the Plan to pay for the office visit (99202). You say that the Plan should pay this claim because the services were required to provide the enrollee with optimum care. The Plan denied your request. The Plan says the services were not approved in advance.
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 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 the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on April 21, 2021 by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Gammagard infusion you received on April 16, 2021.
You asked the Plan to waive the coinsurance for the Gammagard infusion. You say that you shouldn't have to pay this coinsurance because you had an allergic reaction to the Gammagard and you told the nurse that you were allergic to this medication. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that there is no documentation indicating that you had any allergies prior to this visit and there is no documentation that you advised the nurses that you were allergic to Gammagard before you received it.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B drugs.
You have been asked to pay 20% coinsurance for the Gammagard infusion. The Gammagard infusion falls within the Medicare Part B drugs benefit category. This copayment applies regardless of your allergic reaction. 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 the Gammagard infusion you received on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical visit provided on April 26, 2021 by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for the OON medical visit. You say that this was denied for no authorization, but
you believe the medical records show that the service was medically necessary. The Plan denied your request.
The Plan says the services were provided out of network without authorization. As such, denial of payment is
appropriate.
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 the medical visit provided on April 26, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion Interspinous device (22869, 22870).
You asked the Plan to pre-approve the insertion of a Vertiflex Superion Interspinous device. You say that the device is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that the device is helpful for treatment of your health problem.
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 insertion of a 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 record does not document that the enrollee is not indicated for operative intervention at more than two levels. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 the insertion of a Vertiflex Superion Interspinous device have not been met.
Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion Interspinous device (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the home delivered meals, including preparation; per meal, (S5170) provided from February 1, 2021, to February 28, 2021.
You asked the Plan to pay for the homemaker services. You say that you are aware that your plan does not include post hospitalization meal services. You say that you did not actively request the meal service. You also say that it was presented to you, and you merely accepted the benefits. The Plan denied your request. The Plan says homemaker services, including meal delivery services, are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the homemaker services have not been met. Specifically, meal delivery services are not a covered benefit. Therefore, we decided that the Plan does not have to pay for the home delivered meals, including preparation; per meal, (S5170) provided from February 1, 2021, to February 28, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and two or more power seating system motors (E2311), expandable controller (E2377), and a harness for upgrade to expandable controller (E2313).
You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more power seating system motors, expandable controller, and a harness. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that wheelchair accessories are covered when specific criteria are met. 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 an electronic connection between wheelchair controller and two or more power seating system motors, expandable controller, and a harness. Our reviewer says that the items are not medically necessary. Our physician reviewer found the documentation does not reveal that you require other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). You do not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. Your strength in the right upper extremity supports that you can control any power options through their own individual switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electronic connection between wheelchair controller and two or more power seating system motors, expandable controller, and a harness have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and two or more power seating system motors (E2311), expandable controller (E2377), and a harness for upgrade to expandable controller (E2313).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation provided May 26, 2021.
You asked the Plan to pay for the ambulance transportation. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says transportation services from hospital to hospital are not separately payable from the payment to the inpatient institution.
The Plan must follow Medicare rules. Medicare rules say that transportation from one hospital to another is considered "patient transportation" and is covered as an inpatient hospital service. We looked at the file and Medicare rules. In this case, the documentation has determined the enrollee was transported to another inpatient hospital for a higher level of care. This is not separately payable from the inpatient services according to Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation provided May 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Life Alert device (E1399).
You asked the Plan to pre-approve the Life Alert device. You say that the enrollee would benefit from a Life
Alert device due to his multiple medical problems and he lives alone. The Plan denied your request. The Plan
says this is considered a convenience item and not covered by Medicare
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 the Life Alert device (E1399).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan (70450) provided on April 19, 2021.
You asked the Plan to pay for the CT scan. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Medicare guidelines say that ICD-10-CM has a coding convention that requires the underlying condition to be sequenced first, followed by the manifestation. In this case, F05 is a manifestation code and cannot be used as the primary or first-listed diagnosis code on the claim. Therefore, we decided that the Plan does not have to pay for the CT scan (70450) provided on April 19, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical visit provided on March 15, 2021 by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for the OON medical visit. You say that this was denied for no authorization, but the
medical records support the need for the service. The Plan denied your request. The Plan says OON services
must be authorized to be covered. These non-emergency services were correctly 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 the medical visit provided on March 15, 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 continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the criteria for coverage are not 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 the enrollee does not treat with three or more insulin injections per day.
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 a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for observation discharge services (99217) provided on April 3, 2021.
You asked the Plan to pay for the observation discharge services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says because a qualifying initial or subsequent observation care service, or another service resulting in an observation stay has not been reported, the discharge service denied appropriately.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99217 is observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]). We find that CPT code 99217 is not supported in the medical record. Specifically, the documentation submitted does not include evidence that a qualifying initial or subsequent observation care service has been rendered or reported. Based on this information, we decided that Medicare rules for coverage of the observation discharge services have not been met. Therefore, we decided that the Plan does not have to pay for observation discharge services (99217) provided on April 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are functioning at/near your baseline. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasonic guidance provided on February 8, 2021 by non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating 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 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 the ultrasonic guidance provided on February 8, 2021 by non-participating provider.