Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits for the enrollee.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your
request. The Plan says the unique and sophisticated skills of a physical therapist are not required to continue to
treat this condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the visits. Our reviewer says that skilled
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition.
Our physician reviewer found the requested additional therapy is not generally accepted as specific and
effective therapy for the enrollee's condition. The enrollee has had prior therapy for this condition and it does
not appear that the enrollee requires the unique skills of a professional therapist to safely and effectively
provide treatment, that the services can be safely and effectively performed only by a therapist, or under the
supervision of a therapist. The enrollee has been authorized an additional session to review an independent
exercise program. The specialized skill, knowledge and judgment of a qualified therapist is not required to
establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow
further deterioration.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the Intracept procedure at L3, L4, and L5.
You asked the Plan to pre-approve the Intracept procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with intractable low back pain. Functional limitations are noted in activities of daily living. Clinical exam findings are consistent with imaging evidence of severe facet arthropathy and prominent Modic Type II endplate degenerative changes at L3/4 and L4/5. The enrollee has failed conservative treatment, including radiofrequency rhizotomy. The enrollee meets FDA indications for use of the Intracept procedure. There is evidence based medical literature in support of this treatment relative to safety and efficacy in this enrollee's clinical setting. Therefore, the enrollee meets criteria for the request of the Intracept procedure. 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 Intracept procedure have been met. Therefore, we decided that the Plan has to pre-approve the Intracept procedure at L3, L4, and L5.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the facet injection services provided on January 14, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the rules for 
payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 64493 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 facet 
injection services provided on January 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on August 13, 2020.
You asked the Plan to waive the copayment for lab work. You say that you were never told that there would be an additional copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $10 copayment for outpatient diagnostic tests/lab tests. The enrollee has been asked to pay a $10 copayment for lab work. Since lab work was provided, the correct copayment has been applied. Lab work falls within the outpatient diagnostic tests/lab tests benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy services (90832) provided on August 18, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you have been seeking care and treatment with this provider for around 6 years and you do not agree with the denial. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for individual psychotherapy services (90832) provided on August 18, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a 
reasonable expectation that the 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 29, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the office visit provided on June 29, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography services represented by code 70482
and billed for date of service August 22, 2021.
You asked the Plan to pay for code 70482. You say that the medical records provided supports payment for the
code in dispute. The Plan denied your request. The Plan says the provider did not bill a required by Medicare
coding regulations.
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 70482
is a column II code to column I code 70450. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for computed tomography services represented by code 70482 and
billed for date of service August 22, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (82310, 82728, 83540, 83550, 83970, 84100) provided on March 11, 2021.
You asked the Plan to pay for laboratory services. You say that there is no contractual agreement between the laboratory and the facility. The Plan denied your request. The Plan says this is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals for the treatment of end-stage renal disease (ESRD) are included in the ESRD prospective payment system (PPS) as Part B services and are not paid separately. We looked at the file and Medicare rules. The laboratory services at issue were provided for the treatment of ESRD. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (82310, 82728, 83540, 83550, 83970, 84100) provided on March 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not show that an intensive team is needed.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of
rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level
of care (ex. SNF/SAR).
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services requested are medically necessary. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are 
no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan.

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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound behind the abdominal cavity
(76770) provided on August 20, 2021.
You asked the Plan to waive the copayment for an ultrasound. You say that you feel you should not have to pay
$150 for an ultrasound because it is not radiological; it is sound. You also say that you believe the $20
copayment for non-radiological diagnostic services should apply. The Plan denied your request. The Plan says
the cost-sharing was applied correctly. The Plan says the benefits outlined in the 2021 EOC clearly state
ultrasounds are a diagnostic radiology service requiring specialized equipment beyond standard x-ray
equipment.
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 $150
copayment for other outpatient diagnostic tests, not including x-rays.
You have been asked to pay $112.89 in copayments for an ultrasound. Ultrasounds fall within the Outpatient
Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plan only allows the provider to
bill $112.89, which is less than the required $150 copayment listed in the contract. You are responsible for the
lesser amount. 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 ultrasound behind the abdominal cavity
(76770) provided on August 20, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response without transport provided on May 17,
2021.
You asked the Plan to pay for ambulance response with no transport. You say that the Plan should pay for this
service. You were not provided with transport and therefore per Medicare rules, this would not be covered.
Maximus overturned the Plans denial because the response report was not included with the case file. The Plan
requested a reopen and provided the required records.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare does not pay
for ambulance services when there is no transport. The medical records and response report show that the
ambulance was called for abdominal paid, possible due to a pulled muscle. The report states "once in the
ambulance after obtaining a 12 lead, patient stated he felt better and did not want to go to the hospital. Patient
was advised if conditions came back or got worse to go to the hospital." The duration of the response was 15
minutes and resulted in non-transport.
The ambulance company did not provide transport services on May 17, 2021. The ambulance benefit is a
transportation benefit only. When there is no transport, neither Medicare nor the Plan pays for the services
provided. Therefore, we decided that the Plan does not have to pay for ambulance response without transport
provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on May 20, 2021.

You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says this provider is 
not in-network with the Plan's vision provider network.

Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 
these services when provided by the Plan's vision provider network.

We looked at the file and the Plan's rules. The file shows the eye refraction was not provided by the Plan's 
vision provider network. Based on this information, we decided that the Plan's rules for coverage of an eye 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction 
provided on May 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for gene sight testing provided to the enrollee on January 14, 2021.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare coverage criteria were not met. We overturned the Plans denial. The
Plan requested a reopen and provided additional information.
The Plan is correct in this case. The Plan follows Medicare rules. The rules explicitly say that screening tests
are not covered. The Local Coverage Determination L38394 lists specific coverage criteria and
documentation requirements that need to be reflected in the medial records for this testing to be covered by
Medicare. There is no indication in the records provided that this testing was ordered to guide a specific
treatment plan for the enrollee. The required physician documentation also was not submitted in the medical
records. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for gene sight testing provided to the enrollee on January 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to pay for inpatient care provided from May 11, 2020, to May 15, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says this claim was not timely filed. The IRE overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan stated that at the time of service the enrollee was a member of a Medicare-Medicare Plan (MMP) product which requires providers to file claims within 180 days from the date of service. Per the CMS guidelines, timely filing of a claim for MMP contracts is 180 days from the date the services were rendered unless good cause is presented or there are eligibility issues. There was no good cause presented for the untimely filing of the claim and the enrollee did not have any eligibility errors.
The Plan is correct in this case. The Plan follows Medicare rules. The rules say that for MMP Plans, claims for services furnished must be filed no later than 180 days from the date of service. The last date of service was May 15, 2020. The claim was not submitted until January 7, 2021, which was 236 days later. This claim was not timely filed. Therefore, we decided that the Plan does not have to pay for inpatient care provided to the enrollee from May 11, 2020, to May 15, 2020.