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

We decided that the Plan does not have to pre-approve radiofrequency ablation of facet nerves in the back.
You asked the Plan to pre-approve radiofrequency ablation of facet nerves in the back. You say that this request is medically reasonable and necessary. The Plan denied your request. The Plan says the coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that if it has been more than 2 years since the last radiofrequency ablation, diagnostic injections must be repeated before it will be covered. We looked at the file and Medicare rules. In this case, it has been more than 2 years since the last radiofrequency ablation services were performed. Before this can be covered, repeat diagnostic injections must be performed. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation of facet nerves in the back have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of facet nerves in the back.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on July 12, 2021.
You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the charges because you were told to go to the emergency room and had to pay an additional copayment. 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 $65 copayment for urgently needed services. You have been asked to pay a $65 copayment for urgently needed services. Urgently needed services fall within the urgently needed services 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 urgently needed services provided on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on April 22, 2020.
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 provider is not a Medicare eligible dental provider. Maximus
partially overturned the Plans decision. The Plan requested a reopen and stated that even though Medicare does
not cover routine dental services, the Plan contract is clear that the dental services must be rendered by a
provider who is eligible under Medicare.
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 physician or practitioner who has
opted out of the program. The contract also indicated Medicare eligible providers must be used. The records
show this provider indicates they do not accept Medicare payment structures of any kind. Therefore, we
decided that the Plan does not have to pay for dental services provided on April 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September
21, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the denied codes remain not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that the various denied codes are not supported in the medical record. Specifically, the place of service
on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim
reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a
doctor's office (POS 11). 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 pay for laboratory services
provided to the enrollee on September 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular bone graft (21215), a nasal, maxillary, or 
malar area bone graft (21210), and an alveoloplasty (41874). 
 
You asked the Plan to pre-approve a mandibular bone graft, a nasal, maxillary, or malar area bone graft, and an 
alveoloplasty. You say that the requested services are a medical necessity for the enrollee. The Plan denied 
your request. The Plan says rules for coverage have not been met because the requested services are not a 
covered benefit under Medicare or the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
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 mandibular bone graft, a nasal, 
maxillary, or malar area bone graft, and an alveoloplasty. Our reviewer says that the requested services do not 
meet criteria for coverage per Medicare rules. Our physician reviewer found that the requested services  fall into 
the category of treatment involving the structures supporting the teeth (alveolar processes). Therefore, these are 
non-covered expenses as indicated in the Medicare guidelines as dental services involving the care, treatment, 
filling, removal or replacement of teeth or structures directly supporting the teeth. 
 
We looked at this physician's review, the file, and Medicare rules. The physician's review confirmed that the 
requested services are dental services. 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 pre-approve a mandibular bone graft (21215), a nasal, maxillary, or malar area bone graft 
(21210), and an alveoloplasty (41874).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87502, 
87532, 87541, 87581, 87634, 87640, and 87798 provided on September 22, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 are not 
supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect 
the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory 
specimen was obtained in an office, place of service 11; however, the submitted medical documentation and/or 
claim history indicates that the specimen was obtained in a Skilled Nursing Facility place of service 31. 

Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 
87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 provided on September 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 24, 2021, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from October 24, 2021, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from October 
24, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of October 24, 2021, forward. Our physician reviewer found the 
enrollee did not require inpatient mental health treatment beyond October 24, 2021, as she was not a danger to 
herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollee's condition or for the 
purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from October 24, 2021, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 24, 
2021, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you would like an IRF admission covered. The Plan denied your request. The Plan says you do not meet Medicare criteria for admission to an IRF.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulatory infusion pump provided on February 6, 2021. 
 
You asked the Plan to pay for the ambulatory infusion pump. You say that the claim has not been paid in terms 
of the contract for the services provided to this patient. You say that payment should be sent directly to the 
provider. The Plan denied your request. The Plan says the billed code cannot be verified.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the ambulatory infusion pump provided on February 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network exception for out-of-network (OON) physical therapy services.

You asked the Plan to pre-approve an in-network exception. You say that services should be continued and covered under your care. The Plan denied your request. The Plan says there are in-network providers available.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you receive your care from a provider who is eligible to provide services under Original Medicare. 

The requested provider in this case is not a network provider with the Plan. The enrollee has out-of-network benefits. The Plan also has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve the requested exception. Therefore, we decided that the Plan does not have to pre-approve an in-network exception for out-of-network (OON) physical therapy services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee has a history of hypertension and olecranon bursitis and is living at home with weakness. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He is medically stable with no complex nursing or rehabilitation needs. He 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 enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total hip replacement surgery (27130), to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the total hip replacement surgery. You say that the service is medically necessary. The Plan denied your request. The Plan says non-emergent services must be obtained 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 total hip replacement surgery (27130), to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for air ambulance services provided on April 16, 2021.
You asked the Plan to pay for air ambulance services. You say that air transport was requested by the ordering physician at the medical center as medically necessary. The Plan denied your request. The Plan says that the enrollee could have been transported to a closer facility with the same level of care.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 air ambulance services. Our reviewer says that the air ambulance service was medically necessary. Our physician reviewer found that the record indicates that the enrollee, with a history advanced pancreatic cancer, had a pulmonary embolus with free floating cardiac thrombus. The transferring hospital was unable to provide the required clinical services. The enrollee's condition was time critical and required rapid transportation by appropriately trained personnel and properly equipped. The distance precluded ground transportation. The receiving facility accepted the enrollee, a requirement for transportation to occur. The record does not indicate that the receiving facility was chosen for enrollee convenience. The Plan has provided no evidence that the Plan's preferred hospital was able and willing to accept the enrollee. The elements of the coverage rule are satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance services have been met. Therefore, we decided that the Plan has to pay for air ambulance services provided on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) coded 95955 provided on October 1, 2020.

You asked the Plan to pay for the electroencephalogram (EEG). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery).

We find that CPT code 95955 is not supported in the medical record. Specifically, the technical report did not include documentation of lectroencephalogram (EEG) during nonintracranial surgery (carotid surgery); therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the electroencephalogram (EEG) have not been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) coded 95955 provided on October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on November 25, 2020.

You asked the Plan to pay for a lumbar-sacral orthosis. You say that this should be covered. The Plan denied your request. The Plan says there is not a proof of delivery for this item.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery for the supplies provided in this case. The submitted records do not include delivery documentation. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the anticoagulation management services
you received at a cardiologist's office on April 5, 2021, and May 11, 2021.
You asked the Plan to waive the copayments for the anticoagulation management services at a cardiologist's
office. You say that you also had this service on February 12, 2021 but you were not charged a copayment for
that date. You want to know why these dates have a copayment. The Plan denied your request. The Plan says
you were charged these copayments correctly. The Plan says that because the allowed amount for these
services ($11.67 per date of service) is less than your copayment obligation, you are responsible for the full
allowed amount. The Plan says that the reason why you did not have a copayment for the February 12, 2021,
date of service is because the provider for that service is not considered a specialist.
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 $30
copayment for services obtained from a specialist.
You have been asked to pay a $30 copayment for the anticoagulation management services at a cardiologist's
office. Because these services were at a cardiologist's office, these services fall within the services obtained
from a specialist 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 copayments for the anticoagulation
management services you received at a cardiologist's office on April 5, 2021, and May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 15, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 pay for the drug testing services provided on January 15, 2021.