Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a gynecology office visit (99204, 99215) to be provided by an out-of-network (OON) provider.  

You asked the Plan to pre-approve the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says there are network providers available. The services are not emergent.  

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a gynecology office visit (99204, 99215) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for out of network services provided on February 22, 2021. 

You asked the Plan to pay for out of network services. You say that these services should be covered by the 
Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.

The Plan is correct in this case. Medicare rules say that plans can require enrollees to get care from network 
providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only 
in cases involving emergencies, out of area urgent care and pre-approved care. Both providers in this case were 
out of network. The Plan did not pre-approve these services. Therefore, we decided that the Plan does not have 
to pay for out of network lab services provided on February 22, 2021.
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 will benefit from the skills and rehabilitation facility of an IRF. You say that IRF care will also teach your family how to care for you. You say that the notes and information provided support the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the services needed in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for congestive heart failure, respiratory failure, and myocardial infarction. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee 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 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a non-invasive ventilator provided from December 9, 2020, to January 9, 2021.  You asked the Plan to waive the coinsurance for non-invasive ventilator. You say that this equipment was picked up by the provider on January 1, 2021 so you should not be responsible for the full amount of these charges. The Plan denied your request. The Plan says the coinsurance amounts you are being charged are correct.  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 20% coinsurance for non-invasive ventilator. The allowed amounts of these claims total $2,167.12, resulting in a total coinsurance amount of $433.43.  You have been asked to pay 20% coinsurance for non-invasive ventilator. Non-invasive ventilator falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for a non-invasive ventilator provided from December 9, 2020, to January 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from August 5, 2020, through August 18, 2020, billed with principal diagnosis code I12.9 (Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease).

You asked the Plan to pay for the home health services as billed. You say that this claim was billed correctly for the services rendered and was for medically necessary care. The Plan denied your request. The Plan says the documentation does not support the re-certification principal diagnosis as being I12.9. The services rendered were not medically necessary for this condition.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 home health services as billed. Our reviewer says that the home health services provided are not shown to be reasonable and necessary for the treatment of the reported principal diagnosis. Our physician reviewer found the enrollee is noted to have hypertension and kidney disease. These are chronic conditions for which the enrollee will need long-term care. The enrollee does not have documented skilled nursing needs (i.e. IVs, complex wound care, new ostomy). The enrollee has a home blood pressure (BP) monitor and is able to record his own BP measurements, which can then be sent to his physician for review. The documentation does not support that the home health skilled nursing services provided were medically reasonable and necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from August 5, 2020, through August 18, 2020, billed with principal diagnosis code I12.9 (Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) provided April 10, 2021.  You asked the Plan to waive the copayment for the emergency ambulance services. You say that you cannot afford the cost. The Plan denied your request. The Plan says the copayment was applied correctly.  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 $250 copayment for each oneway Medicarecovered ground ambulance trip.  You have been asked to pay a $250 copayment for the emergency ambulance services. The emergency ambulance services fall within the Ambulance 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 the ambulance service, advanced life support, emergency transport, level 1 (A0427) provided April 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve hospice long term care, room and board (code T2046).  

You asked the Plan to pre-approve hospice room and board. The Plan denied your request. The Plan says hospice room and board is not a covered benefit.  

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   

We looked at the file, the Medicare rules and the Plan's rules. The file shows that for hospice services and for services that are covered by Medicare Part A or B and are related to your terminal prognosis: Original Medicare will pay for your hospice services related to your terminal prognosis. While you are in the hospice program, your hospice provider will bill Original Medicare for the services that Original Medicare pays for. Therefore, we decided that the Plan does not have to pre-approve hospice room and board (code T2046).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6539.

You asked the Plan to pre-approve the compression stockings. You say that this equipment is medically necessary for your condition. The Plan denied your request. The Plan says this is statutorily noncovered according to Medicare rules.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6539 are noncovered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6539.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve allograft and autograft for spine surgery.  You asked the Plan to pre-approve the allograft and autograft for spine surgery. You say that this material is used for all procedure and have always been approved. You say that you don't see that the guidelines have changed, this is best for the patient, and the codes should be approved. The Plan denied your request. The Plan says that the requested services are not reasonable and 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 allograft and autograft for spine surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found that the patient is having anterior cervical fusion surgery using a cage. Our reviewer says that local autograft bone use is within the standard of care, so is iliac crest autograft bone. Allograft bone graft extenders such as Grafton may be used in addition to local bone autograft to fill the cage in cases where not enough local autogenous bone can be harvested. Our reviewer says that this should be approved when used in combination with local autogenous bone graft.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of allograft and autograft for spine surgery have been met. Therefore, we decided that the Plan has to pre-approve allograft and autograft for spine surgery.   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 foot orthotics (L3000).

You asked the Plan to pre-approve foot orthotics. You say that the foot orthotics are medically necessary. The
Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace.
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot
orthotics (L3000).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an X-ray of the chest provided on July 29, 2021.  You asked the Plan to waive the copayment for the X-ray. You say that you would like this bill taken care of. The Plan denied your request. The Plan says you have been charged 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 clearly says that you must pay a $45 copayment for basic radiological services provided in a free-standing radiological facility.   You have been asked to pay $30.52, which is less than the $45 copayment for the X-ray. X-rays fall 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 an X-ray of the chest provided on July 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance imaging provided to the enrollee on 
March 6, 2021 and billed under Claim B with code 70553-26.

You asked the Plan to pay for services billed under Claim B. You say that this claim should be paid. The Plan 
denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans 
denial for insufficient claim information in the case file. The Plan requested a reopen and provided additional 
information. The Plan says that Claim B denied because the Plan previously paid for this service under Claim
These services were billed by the same provider group for the same date of service. 

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one 
service is provided on the same day to the same patient by the same physician or more than one physician in 
the same specialty in the same group, only one service may be reported unless the services are for unrelated 
problems. 

Based on the documentation provided, this claim cannot be paid as billed due to the physician group 
relationship between the two providers. Medicare billing criteria were not met. Therefore, we decided that the 
Plan does not have to pay for magnetic resonance imaging provided to the enrollee on March 6, 2021 and billed 
under Claim B with code 70553-26.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a seat lift mechanism.  

You asked the Plan to pre-approve the mechanism. You say that this is medically necessary. The Plan denied your request. The Plan says despite multiple attempts, records were not received.  

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met.  

We looked at the file and Medicare rules. Despite multiple attempts on the plan's part, records were not received to be able to verify if the mechanism should be considered medically reasonable or necessary.        

Based on this information, we decided that Medicare rules for coverage of the mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve sacroiliac joint (SIJ) radiofrequency ablation for the enrollee.  

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and 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 pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Studies completed say that this procedure does not improve outcomes compared to standard treatment of SIJ pain. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically necessary.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint (SIJ) radiofrequency ablation for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the chest (procedure code 71270) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says based on the clinical guidelines, a scan of the blood vessels of the chest is recommended for pulmonary embolism, not just a regular scan of the chest.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 services. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee has possible pulmonary embolic disease. A CT scan of the chest with and without contrast has been ordered but denied. The more appropriate exam for embolic disease is a computed tomography angiography of the chest - 71275. This is the correct exam to address the clinical question. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan of the chest (procedure code 71270) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve hearing aids to be provided by the requested out-of-network provider.  You asked the Plan to pre-approve hearing aids to be provided by the requested out-of-network provider. You say that hearing aids are cheaper with this provider. The Plan denied your request. The Plan says hearing aids through a non-Plan provider is denied because the available medical information does not support the need for an authorization to a non-Plan provider, such as a lack of this specialty provider in the Plan network or an urgent/emergent situation that requires the services of a non-Plan provider.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from an in-network Plan hearing aid provider.  We looked at the file and the Plan's rules. The file shows that the requested provider is not a Plan hearing aid provider. Therefore, we decided that the Plan does not have to pre-approve hearing aids to be provided by the requested out-of-network provider.