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

We decided that the Plan does not have to waive the copayment for a SNF stay provided from December 31, 2020, to February 2, 2021.
You asked the Plan to waive the copayment for a SNF stay. You say that the enrollee contracted the coronavirus while in the facility which required a longer stay. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $20 copayment for days 1-20 and a $100 copayment for days 21-100 for SNF care. The enrollee had a SNF stay from December 31, 2020, to February 2, 2021. Therefore, the enrollee is
responsible to pay $1,200 which is less than the total copayment amount. The enrollee has been asked to pay $1,200 for a SNF stay. A SNF stay falls within the SNF care 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 a SNF stay provided from December 31, 2020, to February 2, 2021.
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT and aquatic therapy visits.
You asked the Plan to pre-approve additional PT and aquatic therapy visits. You say that additional PT and aquatic therapy is medically necessary. The Plan denied your request. The Plan says additional PT and aquatic therapy is not medically necessary.
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 additional PT and aquatic therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by or under the supervision of a therapist. You have been instructed in and are compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT and aquatic therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT and aquatic therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening (81407, 81408, 81479) provided on October 2, 2020.
You asked the Plan to pay for a hereditary cardiovascular screening. You say that this is supported by the records. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular screening have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular screening (81407, 81408, 81479) provided on October 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a supply allowance for a continuous glucose monitor (K0553) provided on March 22, 2021.
You asked the Plan to pay for a supply allowance for a continuous glucose monitor. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
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 relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the provided medical records do not discuss a continuous glucose monitor nor related supplies. 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 supply allowance for a continuous glucose monitor (K0553) provided on March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on December 28, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim must first go to the primary insurer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the services provided on December 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0676).
You asked the Plan to preapprove a pneumatic compression device. You say that the device is necessary to
prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device
is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to preapprove a pneumatic compression device (E0676).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the ambulance response and treatment, no transport, (A0998) provided on March 8, 2021.
You asked the Plan to reimburse you for the ambulance service. You say that the response team advised they were not going to take the enrollee to the emergency room. You say that the enrollee was scheduled to see a nurse the next day for an unrelated follow up. You say that you did not question the response team as the enrollee was not injured. The Plan denied your request. The Plan says if no transport of a Medicare beneficiary occurs, then there is no Medicare-covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on March 8, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Additionally, the record shows that the enrollee singed a transport refusal with the ambulance provider.
Therefore, we decided that the Plan does not have to reimburse you for the ambulance response and treatment, no transport, (A0998) provided on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 19, 2021. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a predictive screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay the entire $1,500 allowance for the complete maxillary denture and complete mandibular denture. We decided that the Plan does not have to pay more than the $1,500 allowance for the complete maxillary denture and complete mandibular denture.
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that you would like to appeal these services. The Plan says that you received dentures and the Plan paid up to the remaining benefit allowance for the year. The Plan also says that the dollar maximum limit has been reached.
We decided that the Plan has to pay the entire $1,500 allowance for the complete maxillary denture and complete mandibular denture.
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. Your 2021 EOC states that you have a $1,500 annual allowance for comprehensive dental services. The record does not show that this benefit has been exhausted. We asked the Plan if and when this benefit was exhausted but did not receive a reply. You reasonably believed these services would be covered under your $1,500 annual dental allowance. Therefore, we decided that the Plan has to pay the entire $1,500 allowance for the complete maxillary denture and complete mandibular denture.
We also decided that the Plan does not have to pay more than the $1,500 allowance for the complete maxillary denture and complete mandibular denture.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a maximum plan benefit coverage amount of $750 every 6 months; any unused amount rolls over for a maximum of $1,500 per year for comprehensive supplemental dental services covered by the Plan. The contract says that you are responsible for any cost above the $750 every 6 months (maximum of $1,500 per year) for comprehensive services. Therefore, we decided that the Plan does not have to pay more than the $1,500 allowance for the complete maxillary denture and complete mandibular denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services.
You asked the Plan to pre-approve acupuncture services. You say that you have used acupuncture in the past and it has helped you with your constant pain. The Plan denied your request. The Plan says the requested procedure does not have enough evidence that consistently shows proof of benefit for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file and Medicare rules. The records show that the requested acupuncture is for treatment of osteoarthritis. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pre-approve acupuncture services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hospital bed, powered air flotation bed, bedside rails and positioning cushion.
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan denied your request. The Plan says that additional records were requested but not received from your provider.
The Plan must follow Medicare rules. Specifically, medical records were not provided for review in this case. The record shows that the Plan made multiple attempts to secure medical records, without success. Without medical records, we cannot determine if Medicare criteria are met in this case. Based on this information, we decided that Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not have to pre-approve a hospital bed, powered air flotation bed, bedside rails and positioning cushion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Relion Prime test strips.
You asked the Plan to pre-approve the Relion Prime test strips. You say that this brand of test strips is medically necessary. The Plan denied your request. The Plan says you must try and fail a preferred glucose test strip/cartridge product that is covered.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. In this case, no medical records were provided to determine why the Plan's preferred brand of test strips would not be appropriate. Based on this information, we decided that Medicare rules for coverage of the Relion Prime test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the Relion Prime test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a neurostimulator (63650).
You asked the Plan to pre-approve implantation of a neurostimulator. You say that this device is medically necessary for the enrollee's pain management. The Plan denied your request. The Plan says the criteria for coverage for the requested device have not been met.
The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator is subject to the criteria listed 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 implantation of a neurostimulator. Our reviewer says that the requested neurostimulator is not medically necessary and reasonable. Our physician reviewer found the patient has not had a documented surgical consultation or a psychological evaluation. The patient does not have an evidence-based indication for a spinal cord stimulator. The request is 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 implantation of a neurostimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of a neurostimulator (63650).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 7, 2021.
You asked the Plan to pay for this service. You say that this physician does not accept any health insurance, but you still believe the Plan should pay for these services. The Plan denied your request. The Plan says your plan does not pay for out of network from providers who are not eligible to accept Medicare payment.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for services provided directly by a physician or practitioner who has opted out of the program. This provider is not a Medicare eligible provider. You did not have prior authorization. You were aware that this provider did not take your insurance. Therefore, we decided that the Plan does not have to pay for physician services provided on April 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care (99223) provided on July 11, 2020.
You asked the Plan to pay for the initial hospital care. You say that the services were medically necessary and supported by the provided documentation. The Plan denied your request. The Plan says incorrect or incomplete documentation was submitted for medical review, and the services cannot be approved for payment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that providers must report services correctly. Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history, a comprehensive exam and medical decision making of high complexity. 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 the initial hospital care. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case, and there is not sufficient documentation to support that this service is appropriate as billed. Our physician reviewer found that the documentation provided did not meet criteria for coverage of code 99223. Specifically, there was no medical decision making of high complexity. The review has determined that the items/services at issue in this case are not medically reasonable or necessary as billed. There is not sufficient documentation to support that the services are appropriate as billed. 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 initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99223) provided on July 11, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) provided on January 17, 2021.
You asked the Plan to pay for a PET scan. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with an appropriate diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate diagnosis code. We looked at the file and Medicare rules. The billed diagnosis code, C85.90, is not listed as an appropriate code. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met.
Therefore, we decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) provided on January 17, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the problem focused limited oral evaluation (D0140) provided on June 23, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this was not a routine office visit, but one concerning your continuing tooth/jaw problem. The Plan denied your request. The Plan says that this service is limited to one time in a 12-month period. The Plan also says that you received your one allotted periodontal service on October 22, 2020.
The Plan must follow Medicare rules. The rules say that the health plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. The record shows that you received a problem focused limited oral evaluation (D0140). The 2021 EOC says you are allowed 2 oral exams per calendar year. The contract does not clearly state what types of oral exams are covered. No documentation was provided showing you have exhausted your oral exams benefit. You reasonably believed that this service was considered an oral exam and would be covered. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the problem focused limited oral evaluation have been met. Therefore, we decided that the Plan has to pay for the problem focused limited oral evaluation (D0140) provided on June 23, 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.