Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
You asked the Plan to provide a therapeutic continuous glucose monitor. You say that you want a CGM for short term use to monitor your blood sugar and adjust your diet. The Plan denied your request. The Plan says you are not using insulin.
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 use insulin with at least
three daily injections. 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 provide a therapeutic continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that you've attached last year's (2020)
authorization approval for essentially the same thing. These are medically necessary, and you need to wear
them on a daily basis. The Plan denied your request. The Plan says this item is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 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 A6533.
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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for chest pain and had
coronary artery bypass grafting. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided on May 7, 2021.
You asked the Plan to pay for an x-ray. You say that thos is not a duplicate service. The Plan denied your request. The Plan says this is not separately payable.
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 code 71045
has a bundled relationship with code 74022 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for an x-ray (71045) provided on May 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided May 7, 2021.
You asked the Plan to pay for the core buildup. You say that your dentist was told that the services were covered 100%. The Plan denied your request. The Plan says this service is 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 core buildup, including any pins when required (D2950) provided May 7, 2021.
Your complaint about a plan representative potentially providing misinformation 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from April 5,
2019, to April 30, 2019.
You asked the Plan to pay for the SNF care. You say that somehow the claim was never transmitted to the plan.
You also say that the care provided was necessary. The Plan denied your request. The Plan says the original
claims were processed on January 7, 2020, and January 10, 2020. The Plan says that corrected claims were not
received until June 28, 2021. The Plan also says that this is past the allowed 12-month timeframe.
The Plan follows Medicare rules. The rules say that a contractor may reopen and revise its initial determination
or redetermination on its own motion within 1 year from the date of the initial determination or redetermination
for any reason.
The record shows that a corrected claim for the SNF care was not filed until June 9, 2021. This means that
more than 1 year from the initial submission had passed before a corrected claim was filed. Therefore, we
decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from April 5,
2019, to April 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multiple extractions, alveoloplasty, and anesthesia.
You asked the Plan to pre-approve the extractions, alveoloplasty, and anesthesia. The Plan denied your request. The Plan says these services are not covered benefits.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve 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 pre-approve multiple extractions, alveoloplasty, and anesthesia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi electric hospital bed ( E0261).
You asked the Plan to pre-approve a semi electric hospital bed. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.
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 item is not medically necessary. Our physician reviewer found the patient was able shift back and forth in the wheelchair to be examined and also able to stand. The patient's condition does not require position of the body in ways not feasible in an ordinary bed and does not require frequent changes in body position or require special attachments that cannot be fixed and used on an ordinary 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 ( E0261).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services performed by a qualified physical therapist (G0151), services performed by a qualified occupational therapist (G0152), and direct skilled nursing services of a RN (G0299).
You asked the Plan to pre-approve the services performed by a qualified physical therapist, occupational therapist, and direct skilled nursing services of a RN. The Plan denied your request. The Plan says these services are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services performed by a qualified physical therapist, occupational therapist, and direct skilled nursing services of a RN. Our reviewer says that these services are not medically reasonable or necessary. Our physician reviewer found you do not have documented skilled nursing needs. Our reviewer found that you do not have documented skilled therapy needs. Our physician reviewer also found that your care needs appear to be custodial. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services performed by a qualified physical therapist, occupational therapist, and direct skilled nursing services of a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve services performed by a qualified physical therapist (G0151), services performed by a qualified occupational therapist (G0152), and direct skilled nursing services of a RN (G0299).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on April 29, 2021.
You asked the Plan to waive the copayment for an EGD. You say that you do not understand why the charges are so high. 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 $395 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay the allowed amount of $340.25, which is less than the $395 copayment for an
EGD. An EGD falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 an EGD provided on April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical boot (L3260).
You asked the Plan to pre-approve a surgical boot. You say that you need this to be able to walk. The Plan
denied your request. The Plan says this is not covered for you condition.
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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve a surgical boot (L3260).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to provide services with a Licensed Marriage & Family Therapist.
You asked the Plan to provide services with a Licensed Marriage & Family Therapist. You say that this provider has been helping you with anxiety. The Plan denied your request. The Plan says the provider is an ineligible mental health provider.
The Plan follows Medicare rules. Medicare rules say that no Medicare payment may be made for items or services provided directly by a physician or practitioner who is not eligible to enroll in Medicare. In this case, the requested provider is not qualified to receive payment under Medicare or the benefit plan. Therefore, we decided that the Plan does not have to provide services with a Licensed Marriage & Family Therapist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit (CPT code 99205) with an out-of-network provider.
You asked the Plan to pre-approve the office visit. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says medically necessary care is available in-network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit (CPT code 99205) with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (K0800).
You asked the Plan to pre-approve a power mobility device. You say that you need this for various health issues including your recent risk of falling. The Plan denied your request. The Plan says the submitted medical records do not support this is necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file does not show that your condition cannot be ameliorated by a walker, cane or manual wheelchair and does not address whether you are capable of safely operating the PMD. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device (K0800).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 7, 2021.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.
We looked at the file and Medicare rules. The file does not contain documentation of an established
relationship between the enrollee and the ordering provider. Without a record showing that this provider is
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the
Plan does not have to pay for the laboratory services rendered on February 7, 2021.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pay for 95865, 95868. We decided that the Plan does not have to pay for
95955, 95861, and 95927.

You asked the Plan to pay for the denied code. You say that this should be paid for. The Plan says that the
denied codes remain not supported.

We decided that the Plan has to pay for 95865 and 95868.

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 the denied codes is:

CPT 95865:

Needle electromyography; larynx

CPT 95868:

Needle electromyography; cranial nerve supplied muscles, bilateral

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 for CPT 95865 and CPT 95868. Our reviewer says that
these codes were supported by the medical records. Our physician reviewer found that these procedures were
documented on the technical report on page one. Therefore, they are confirmed as performed and coded
correctly.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 95865, 95868 have been met. Therefore, we decided that the Plan has to pay for
95865 and 95868.

We also decided that the Plan does not have to pay for 95955, 95861, and 95927.

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 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 for CPT 95955, 95861, 95927. Our reviewer says that
these codes were not supported by the medical records. Our physician reviewer found that the technical record
does not document the rendering of CPT 95955. There is a more appropriate code to use for continuous
monitoring. Any additional EEG is included in the primary code. The denied code is used for special EEG tests
and should not be used for this service performed. The technical report does not document the rendering of
CPT 95861 of CPT 95927.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 95955, 95861, 95927 have not been met. Therefore, we decided that the Plan
does not have to pay for 95955, 95861, and 95927.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiofrequency ablation (RFA) of the sacroiliac (SI) joint rendered on February 24, 2021.

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 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has chronic low back pain and has tried physical therapy and non-steroidal anti-inflammatory drugs (NSAIDs) in the past. The requested RFA of the left SI joint is considered experimental/investigational in nature and is therefore not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. 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 pay for the radiofrequency ablation (RFA) of the sacroiliac (SI) joint rendered on February 24, 2021.

Local Coverage Determination (LCD) L33622 and Local Coverage Article (LCA) A52863 referenced by the Plan are not binding for the services at issue and were not used in the Maximus determination.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care provided on January 12, 2021.
You asked the Plan to pay for the services provided. You say that the services were provided in good faith. The Plan denied your request. The Plan says the billed code is not supported by the medical documentation submitted.
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 99223 is Initial hospital care, per day, for the evaluation and management of a patient. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. We looked at the file and the rules. We find that CPT code 99223 is not supported in the medical record. Specifically, the records do not indicate how much time was spent with the enrollee. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care provided on January 12, 2021.