Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the complicated wound repair provided on December 2, 2020.
You asked the Plan to pay for the complicated wound repair. You say that the denial is incorrect as the medical records support the services billed. You say that the records should be reviewed, and the claim allowed for payment of all charges. The Plan denied your request. The Plan says the records do not support the services 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.
In this case, the CPT Code Manual definition of code 13121 is repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm. The definition of code 13122 is repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure)
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 the complicated wound repair. Our reviewer says that the services do not meet the criteria for billing or reimbursement consideration. Our reviewer found that the medical records provided do not include sufficient documentation to validate that a repair, complex, scalp, arms, and /or legs; 2.6.cm to 7.5 cm was performed. Our reviewer says that CPT 13122 is an add-on code and is only payable if the primary code is eligible for payment. In this case, CPT 13121, the primary code was denied, therefore 13122 is not eligible for reimbursement consideration. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the complicated wound repair have not been met. Therefore, we decided that the Plan does not have to pay for the complicated wound repair provided on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 10, 2020 by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that the enrollee needed your help and you don't want to leave a patient with stress not having a facility to check their health. The Plan denied your request. The Plan says prior authorization was not obtained as required.
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 November 10, 2020 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of stroke with left hemiplegia and is living at home with ongoing weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy
program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for compression stockings purchased May 14, 2021 coded as A6530.
You asked the Plan to pay for compression stockings coded as A6530. You say that these compression stockings should be covered by the Plan. The Plan denied your request. The Plan says these compression stockings were purchased out of network and are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 pay for compression stockings purchased May 14, 2021 coded as A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the acupuncture services (97811, 97810) provided May 11, 2021.
You asked the Plan to waive the copayment for the acupuncture services. You say that the cost of each visit is $80. You received a payment of $60.79 but in the past, you have been reimbursed the full $80 for this same provider and service. The Plan denied your request. The Plan says the plan reprocessed the claim and issued additional payment for full reimbursement minus the $15 copayment.
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 $15 copay for each Medicare covered acupuncture visit. You have asked for full reimbursement of $80 for the acupuncture services. The plan has reimbursed you $65 ($80 payment minus the $15 copayment). The acupuncture services fall within the Acupuncture for chronic low back pain 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 the acupuncture services (97811, 97810) provided May 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF admission.
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says the information submitted does not show that you have a medical need for this service.
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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF admission.
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 a SNF admission. You say that the enrollee needs short term rehab. The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing services.
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 a SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular radiofrequency ablation to the left knee for the
enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is considered experimental, investigational, and unproven.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this is considered an experimental/investigational therapy and it is the subject of on-going clinical trials.
Therefore, the request is deemed not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve genicular radiofrequency ablation to the left knee for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You have been refusing therapy participation. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in the SNF. As a practical matter, you do not require the necessary services on an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the services (70551) provided on May 7, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is a bundled
service.
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 argues that a Procedure to Procedure (PTP) edit exists between codes
70551 and 70552, which is true. However, the Plan has not provided documentation showing that code 70552
was billed on the same date of service as code 70551. Without supporting documentation, the Plan's denial
cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (70551) provided on
May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes (CPT code 97140) and electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care (CPT code G0283) provided to the enrollee on March 8, 2021.
You asked the Plan to pay for the services. You say that you were advised to bill these claims to the Plan. The Plan denied your request. The Plan says they only cover manual manipulation of the spine to correct subluxation.
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. Therefore, we decided that the Plan does not have to pay for manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes (CPT code 97140) and electrical stimulation
(unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care (CPT code G0283) provided to the enrollee on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a retainer crown (D6740) for tooth #8 for use in a fixed bridge covering tooth space #7.
You asked the Plan to pre-approve the retainer crown. You say that this should be covered. You state that the prior crown was paid by your employer provided dental plan and not the current plan. The Plan denied your request. The Plan says that coverage was provided for a crown on tooth #8 in June 2017. As such, a new crown cannot be approved.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers crowns and fixed bridges as described in the Medicare rules section. We reviewed the file and the contractual language in the Dental Benefits Addendum. We find that the denial of coverage in this case is not supported. There are two main issues for which the denial is not deemed valid in this case. Firstly, as noted in the contract, though there is a one-per-60-month limit on crowns, there is an exception when it is determined that the crown cannot be made satisfactory due to changes in the patient's dental health. The Plan did not indicate that they reviewed whether the exception criterion was met, nor were dental records or dental x-rays submitted to Maximus to allow for an independent review to be performed. The second issue is that, while the Plan has shown that a crown was placed in 2017 on tooth #8, this was a standard porcelain crown coded as D2740. The crown being requested in this case is an integral part of a fixed denture/bridge. This is a different type of crown and is considered to be part of the fixed denture. As such, payment for a crown not associated with a fixed denture in the last 60 months does not necessarily exclude coverage for the fixed denture crown. Based on the entirety of the available information, we find that the denial for coverage for this service has not been substantiated. Therefore, we decided that the Plan has to pre-approve a retainer crown (D6740) for tooth #8 for use in a fixed bridge covering tooth space #7.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code 81518) provided on January 22, 2020.
You asked the Plan to pay for the laboratory services. You say that you were not informed by the doctor's office that your testing would be done out-of-network or how expensive this test would be. The Plan denied your request. The Plan says the provider did not submit the claim timely. The Plan has stated that you (the member) will not be held liable.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the laboratory services was not filed until June 17, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. The Plan has stated that you (the member) will not be held liable. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code 81518) provided on January 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you have therapy need and would benefit from an inpatient stay. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for chest pain. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need acute rehabilitation to further your recovery and would benefit from having therapies every day. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a
need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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 IRF admission and services.