Persius/hicric huggingface dataset:
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 is living at home with continued
weakness after a hospitalization in October 2021 for extensive surgical debridement of sternal wound from
coronary artery bypass graft surgery in 2020. Your 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 patient has a need
for physical and/or occupational therapy, there is no documentation of a need for an intensive 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance services provided on May 20, 2021.  You asked the Plan to pay for the ambulance services. You say that you are only liable for no more than the copayment amount which is $250. The Plan denied your request. The Plan says the provider is showing liability for the denied charges using a modifier that Medicare states do not meet the criteria to be paid. The non-contracted provider is balance billing the member.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. The Plan is not holding you liable for the ambulance services. The record indicates that you are being balance billed by the provider. The balance bill is not your responsibility or the responsibility of the Plan. Please contact your Medicare Regional Office with any questions or concerns about this bill. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to waive the cost share for the SPECT test, the medical supply, and the Part B injection provided on May 7, 2021.  You asked the Plan to waive the cost share for the myocardial SPECT test, the medical supply, and the Part B injection. You say that you were never informed of the cost sharing for the services. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing 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 does not say in clear and accurate terms how much you should expect to pay for the SPECT test.   We looked at your contract with the Plan. We did not see where the contract says enrollees must pay $300 for the SPECT test. The Plan contract does not clearly disclose when you should expect to pay $75 to $300 for a specific diagnostic radiology service. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the cost share for the myocardial SPECT test on May 7, 2021.  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 did not submit the allowed amounts for the medical supply and the Part B injection on the Explanations of Benefits. This means we are unable to determine if the coinsurance amounts you are being asked to pay are correct. Therefore, we decided that the Plan has to waive the cost share for the medical supply, and the Part B injection provided on May 7, 2021.   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.  Your complaint that the physician's office committed fraud 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the routine transportation provided August 9, 2021, to August 16, 2021.  You asked the Plan to pay for the additional routine transportation beyond the Plan's trip limit. You say that you were not told you were at your ride maximum, and you need the rides to get to your appointments. The Plan denied your request. The Plan says you exceeded the number of covered trips.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 8 trips per year.   We looked at your request, the records in the case file, and the rules. The Plan provided documentation showing that 8 trips were covered prior to August 9, 2021. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pay for the routine transportation provided August 9, 2021, to August 16, 2021.   Your complaint about issues you have had with transportation and communication 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 5, 2021.  You asked the Plan to pay for the dental service. You say that this was just a teeth cleaning and should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 36 months. The Plan also says that the frequency limit has been exceeded.  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 and comprehensive oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on August 12, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that this equipment is necessary. The Plan denied your request. The Plan says this item is statutorily non-covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a diagnostic test provided on August 31, 2021.  You asked the Plan to waive the copayment for a diagnostic test. You say that in previous years you have never paid a $55 copayment for an office visit. The Plan denied your request. The Plan says in previous years the copayment has always been the same with a $30 copayment for the office visit and a $25 copayment for the diagnostic test. The proper copayment was 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). Your contract with the Plan clearly says that you must pay a $25 copayment for Medicare-covered non-radiological diagnostic services.     You have been asked to pay a $25 copayment for a diagnostic test. A diagnostic test falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 a diagnostic test provided on August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an outpatient office visit (99214) provided on August 24, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an outpatient office visit. You say that the patient has recently moved from a different state and was seen in the emergency department, which asked the patient to follow up with their primary care physician (PCP). The Plan denied your request. The Plan says services were rendered by a non-participating provider without prior authorization. The Plan also says there are no indications that the enrollee was referred for services with this provider by an in-network provider.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an outpatient office visit (99214) provided on August 24, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the umbilical hernia repair (49585) provided on June 29, 2021.  You asked the Plan to pay for the umbilical hernia repair (49585). You say that a separate incision was made to repair the hernia and the codes do not bundle. You say that the records support the separate billing. The Plan denied your request. The Plan says the requested procedure code 49585 would be considered inclusive to procedure code 44204-AS.  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 49585 is repair umbilical hernia, age 5 years or older; reducible.  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 umbilical hernia repair (49585). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for billing or reimbursement consideration. A hernia repair is separately reportable if it is performed at a site other than the incision. Our reviewer found that the medical records submitted do not include sufficient documentation that the hernia repair was a distinct separate procedure, therefore code 49585-AS cannot be verified.   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 umbilical hernia repair (49585) have not been met. Therefore, we decided that the Plan does not have to pay for the umbilical hernia repair (49585) provided on June 29, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the central motor evoked potential study coded 95939, the short-latency somatosensory evoked potential study coded 95938, the needle electromyography coded 95861, and the continuous intraoperative neurophysiology monitoring coded G0453 provided on April 9, 2021.  You asked the Plan to pay for the central motor evoked potential study, the short-latency somatosensory evoked potential study, the needle electromyography, and the continuous intraoperative neurophysiology monitoring. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services billed have a lack of clinical information.  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. Review of the file shows that the case file submitted to Maximus was largely incomplete. The documentation states that these services were denied due to lack of clinical information. The documentation also states that the claim was originally denied due to timely filing. However, per Medicare rules, the provider has one calendar year after the date of service to submit the claim. Per the documentation, the claim was submitted timely. No other documentation on why these services were denied was provided to Maximus.  This means that the Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the central motor evoked potential study coded 95939, the short-latency somatosensory evoked potential study coded 95938, the needle electromyography coded 95861, and the continuous intraoperative neurophysiology monitoring coded G0453 provided on April 9, 2021.   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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen concentrator.  You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says oxygen is only being used at night.  The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.    To qualify for home oxygen, the patient must meet one of the following blood gas levels:  1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;  2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;   3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;  4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.  For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.  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 concentrator. Our reviewer says that the requested concentrator is not medically reasonable or necessary. Our physician reviewer found a portable oxygen concentrator is not medically necessary because the coverage criteria have not been met. You have chronic obstructive pulmonary disease (COPD) and  obesity hypoventilation syndrome (OHS), and is on oxygen at night. The clinical notes from 8/16/21 document hypoxemia with ambulation, but there is no documentation of ambulation with oxygen to establish the flow rate needed to correct the hypoxemia. Apparently, there is also no order for portable oxygen. Coverage criteria are not met for any form of portable oxygen.  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 concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a radiofrequency ablation (RFA) of the nerves innervating the sacroiliac joint (64625) provided on June 2, 2021.  You asked the Plan to pay for an RFA of the sacroiliac joint. You say that the procedure at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the procedure at issue is experimental/investigational.  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 an RFA of the sacroiliac joint. Our reviewer says that the services at issue are not considered medically reasonable and necessary in this case. Our physician reviewer found that the procedure at issue is considered an experimental/investigational procedure because of the wide variation in efficacy reported in the literature.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an RFA of the sacroiliac joint have not been met. Therefore, we decided that the Plan does not have to pay for a radiofrequency ablation (RFA) of the nerves innervating the sacroiliac joint (64625) provided on June 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Visudyne for the enrollee.  You asked the Plan to pre-approve the drug. 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 a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of central serous retinopathy. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved  drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.  he elements of the coverage criteria are not 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Visudyne for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a semi-electric hospital bed.  You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is not met.  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 the bed. Our reviewer says that the requested bed is not medically reasonable or necessary. Our physician reviewer found there is no documentation that your condition requires position of the body in ways not feasible in an ordinary bed. You do not require frequent changes in body position or immediate changes in body position. Your condition does not 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 the bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Lantus.  You asked the Plan to pre-approve Lantus. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lantus.   Benefits for Lantus may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.