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

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve the SNF services. You say that the enrollee is still in the hospital, is ready for discharge, but cannot discharge home safely. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the services needed can safely be received at a different setting.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and tested positive for a coronavirus infection. The enrollee received physical therapy, speech therapy, and occupational therapy. The enrollee was at a maximal assist level for functional mobility. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.  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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that you are in the hospital and waiting for approval to the SNF. The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of SNF care. The Plan says that the enrollee's needs can safely be met in an alternate level of care.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, was not hypoxic and remained asymptomatic from her coronavirus infection. The enrollee received physical therapy and occupational therapy. The enrollee was at a standby assist to contact guard assist level with functional mobility. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on July 15, 2021, through July 22, 2021.  You asked the Plan to waive the copayment for the inpatient hospital care. You say that you should not have to pay a cost share. The Plan denied your request. The Plan says the cost share 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 $220 copay per day one through five for inpatient hospital care.   You have been asked to pay a $220 copay per day one through five for the inpatient hospital care. This service falls within the inpatient hospital care 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 inpatient hospital care provided on July 15, 2021, through July 22, 2021.   Your complaint about potentially not being treated for all of your symptoms 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the testing services rendered on July 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 procedure code 95957 is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.   In this case, the CPT Code Manual definition of code 95957 is digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis).  We find that CPT code 95957 is not supported in the medical record. Specifically, there is no documentation of time spent on the digital analysis. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the testing services rendered on July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the SelectMDx testing (81479) provided on May 28, 2021.  You asked the Plan to pay for the SelectMDx testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that code 81479 is not considered medically necessary when used for SelectMDx.  We looked at the file and Medicare rules. The testing at issue is not considered medically necessary. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing (81479) provided on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing (81455) provided on June 8, 2021.  You asked the Plan to pay for code 81455. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file and Medicare rules. Medicare says that genetic testing submitted under code 81455 will be denied as not medically necessary as it is unlikely to impact therapeutic decision-making in the clinical management of the enrollee. Therefore, we decided that the Plan does not have to pay for the genetic testing (81455) provided on June 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drug provided in an outpatient setting on September 24, 2021.  You asked the Plan to pay for the self-administered drug. You say that you received prior authorization for this claim. The Plan denied your request. The Plan says the drug you received is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug you received is not covered under Medicare Part B.  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 pay for the self-administered drug provided in an outpatient setting on September 24, 2021.   Benefits for the self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for the x-ray provided on March 22, 2021, and July 2, 2021.  You asked the Plan to reduce the copayment for the x-ray . You say that you should have been charged $20 for the x-ray.  The Plan denied your request. The Plan says 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 clearly says that you must pay a $95 copayment for basic radiological services at an in-network outpatient hospital.   You have been asked to pay a $95 copayment for the x-ray.  The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed by the outpatient hospital system. 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 reduce the copayment for the x-ray provided on March 22, 2021, and July 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for occupational therapy provided by an out-of-network provider, at the time, on May 10, 2021.  You asked the Plan to waive the copayment for occupational therapy. You say that this provider is in-network. 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). Your contract with the Plan clearly says that you must pay a $55 copayment for outpatient rehabilitation services/out-of-network.   You have been asked to pay a $55 copayment for occupational therapy. The rendering physician became in-network on October 1, 2021. These services were rendered prior to being in-network; therefore, the correct copayment has been applied.  Occupational therapy falls within the outpatient rehabilitation services/out-of-network 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 occupational therapy provided by an out-of-network provider, at the time, on May 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from February 13, 2020, to February 26, 2020.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there are inconsistences between the documentation in the medical records and the coding of the 5 day Minimum Data Set (MDS) assessment.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We asked our 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the case file does not contain provider documentation of an active diagnosis of ulcerative colitis, Crohn's disease, or inflammatory bowel disease, and morbid obesity.  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 pay for skilled nursing facility (SNF) services provided to the enrollee from February 13, 2020, to February 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an excision of parotid tumor or gland (42415) provided on July 29, 2021.  You asked the Plan to waive the copayment for an excision of parotid tumor or gland. You say that the procedure at issue was erroneously processed as outpatient. The Plan denied your request. The Plan says the correct 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 $275 copayment for outpatient hospital visits.   In this case, the claim at issue was submitted as an outpatient. The case record does not support that you were admitted as an inpatient for the procedure at issue. You have been asked to pay a $275 copayment for an excision of parotid tumor or gland. An excision of parotid tumor or gland falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 excision of parotid tumor or gland (42415) provided on July 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital care (99232) provided April 27, 2021.  You asked the Plan to pay for the hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not billed with a valid diagnosis code.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.        We find that CPT code 99232 is not supported in the medical record. Specifically, diagnosis code  R87.5 is a female only diagnosis code. The record shows the patient is male. Based on this information, we decided that Medicare rules for coverage of the hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99232) provided April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for removal of a Torus Mandibularis provided on February 3, 2021.
You asked the Plan to pay for this service. You say that these dental services should be covered by the Plan.
The Plan denied your request. The Plan says while the extractions were paid, removal of a Torus Mandibularis
is not a covered benefit. Maximus partially overturned the Plans denial approving payment of the extractions
only. The Plan requested a reopen and stated the extractions were already approved for payment.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Both the Plan and the
IRE agree that the extractions are covered and removal of a Torus Mandibularis are not. Therefore, we decided
that the Plan does not have to pay for removal of a Torus Mandibularis provided on February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional unit of code 84165 provided on July 12, 2021.  You asked the Plan to pay for the additional unit of code 84165. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  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 84165 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 additional unit of code 84165 have not been met. Therefore, we decided that the Plan does not have to pay for the additional unit of code 84165 provided on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the complete lower denture provided on June 1, 2021.
You asked the Plan to pay for the complete lower denture. You say that the only denture you received was an upper denture in 2011. You say that you have not received any other denture work in the last 5 years, and this should be a covered service. The Plan denied your request. The Plan says that the claim denied correctly.
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 documentation submitted does not support a complete lower denture was provided within 5 years to exhaust your benefit. The Plan only submitted proof that a complete upper denture was provided in 2011. Therefore, we decided that the Plan has to pay for the complete lower denture provided on June 1, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 We decided that the Plan has to waive the deductible for the OON specialist office visit. We decided that the Plan does not have to waive the coinsurance for the OON specialist office visit.   You asked the Plan to waive the deductible for the OON specialist office visit. You say that you would like the Plan to reconsider your request. The Plan says that the correct cost share has applied.  We decided that the Plan has to waive the deductible for the OON specialist office visit.   The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance).  We also decided that the Plan does not have to waive the coinsurance for the OON specialist office visit.  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 50% coinsurance for OON specialist visits. The Plan contract clearly says physician specialist services do not apply to deductible charges. The allowed amount is $75.16. Per the Plan's contract, you are only responsible for 50% of the allowed amount of $75.16, which is $37.58. Therefore, we decided that the Plan does not have to waive the coinsurance for the OON specialist office visit.  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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on March 10, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on January 8, 2021.  You asked the Plan to pay for lab tests. You say that there is no contractual agreement in place which indicates that these codes are included in the dialysis rate. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is included in the end-stage renal disease (ESRD) prospective payment system (PPS) rate and is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that lab services furnished to individuals for the treatment of ESRD are included in the ESRD PPS and are not paid separately.      We looked at the file and Medicare rules. These lab services are included in the ESRD PPS and are not separately payable. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Vitamin D Assay testing with code 82306 provided on February 4, 2021  You asked the Plan to pay for the Vitamin D Assay testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are 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, the Vitamin D Assay testing, 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 Vitamin D Assay testing with code 82306 provided on February 4, 2021