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

We decided that the Plan does not have to pay for prolotherapy, transcutaneous electrical nerve stimulator (TENS) and supplies, and a pneumatic device provided on August 26, 2021.
You asked the Plan to pay for the outpatient therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services you received are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient therapy services have not been met. Review of the file and publicly available
records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to pay for prolotherapy, transcutaneous electrical nerve stimulator (TENS) and supplies, and a pneumatic device provided on August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal implants (D6010).
You asked the Plan to pre-approve the endosteal implants. You say that you would like to appeal these services because you have issues eating. The Plan denied your request. The Plan says endosteal implants are not covered under your benefit plan.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal implants (D6010).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for continued inpatient hospital care for the enrollee.
You asked the Plan to pay for continued inpatient hospital care for the enrollee. You say that continued
inpatient admission was medically necessary. The Plan denied your request. The Plan says at the time of the
appeal, an inpatient level of care was no longer necessary for the enrollee based on Medicare guidelines.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for continued
inpatient hospital care. The Maximus Physician Reviewer determined that the documentation supports that the
criteria for inpatient payment are met in this case. The reviewer found the review has determined that the
record showed that at the time of inpatient admission the admitting physician reasonably expected that the
patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.
According to the documentation, she was not participating with therapy and therefore did not qualify for skilled
nursing rehab. At the time of the appeal the discharge plan for long-term care and the case manager was
working with her family to transition to a long-term care facility. The Plan requested a reopen and argued that
as a Medicare Advantage plan, inpatient authorization requests are reviewed based on medical necessity only.
The medical records show the enrollee was a 79-year-old woman who was admitted to the hospital on
November 3, 2021, with encephalopathy which was lost likely related to a urinary tract infection. On
November 13, 2021, it is documented that the encephalopathy did not change with treatment of the UTI. Per
the enrollee's nephew and primary care physician, the enrollee was not far from her most recent baseline, with
a steady cognitive decline over many months.
On November 16, 2021, it is documented that the enrollee's cognitive impairment was most consistent with
dementia, with a possible contribution from depression, and possible superimposed delirium. The treatment
plan included pursuing discharge with possible rehabilitation and long-term care placement. The records show
inpatient admission was authorized by the plan from November 3, 2021, to November 18, 2021. At that point,
the documentation does not support that continued inpatient hospital care was medically reasonable and
necessary for the enrollee in this case, as the acute medical problems had been addressed, the enrollee had
returned to near her baseline, and discharge with rehabilitation and long-term care were being pursued.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued inpatient hospital care have not been met. Therefore, we decided that
the Plan does not have to pay for continued inpatient hospital care for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the dialysis services provided from January 2, 2021, through March 31, 2021.
You asked the Plan to pay for the dialysis services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that this claim has not been billed in accordance with Medicare coding regulations.
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. In this case, the Plan has failed to forward a claim to show what was billed. Without any kind of claim form that shows what the provider has billed, we are unable to evaluate whether the claims in question have been billed in accordance with Medicare rules. Therefore, we decided that the Plan has to pay for the dialysis services provided from January 2, 2021, through March 31, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on April 25, 2021.

You asked the Plan to pay for the transportation services. You say that the services should be covered. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 transportation services. Our reviewer says that the non-emergency transportation services are not medically necessary. Our physician reviewer found the provided documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee on April 25, 2021. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport.

The reviewer also found that he documentation does not support that the ambulance transport was medically reasonable and necessary for the enrollee as defined by Medicare criteria. 

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 transportation services have not been met. Specifically, the file does not show that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on April 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs received on July 20, 2021 and July 21, 2021.
You asked the Plan to pay for the drugs. You say that this should be paid for. The Plan denied your request. The Plan says this is not a covered 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 pay for self-administered drugs received on July 20, 2021 and July 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on
September 30, 2021.
You asked the Plan to pay for code 70450. 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 as billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on
September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lab testing (81240, 81241).
You asked the Plan to pre-approve the lab testing. You say that this testing is medically necessary. The Plan denied your request. The Plan says this testing is not covered.
The Plan must follow Medicare rules. Medicare rules say that genetic testing for these genes for all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered. We looked at the file and Medicare rules. This procedure is non-covered. Based on this information, we decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not have to pre-approve lab testing (81240, 81241).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says there is a lack of any acute symptoms.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued services. Our physician reviewer found that active treatment was not taking place. It did not appear that the services were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis.
The enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations. He was not showing any aggressive behaviors while being cooperative and compliant. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a primary care office visit provided on May 19, 2021.  

You asked the Plan to waive the copayment for office visit. You say that your purse was stolen and you cannot afford this amount. The Plan denied your request. The Plan says the copayment amount you are being charged is 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 $10 copayment for in-network primary care visit.         

You have been asked to pay $10 copayment for office visit. Office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 primary care office visit provided on May 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator trial (63650).
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that this is medically reasonable and
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that a spinal cord stimulator trial can be covered only for
patients who have undergone careful screening, evaluation, and diagnosis by a multidisciplinary team prior to
implantation. Such screening must include a psychological evaluation.
The file does not show that a psychological evaluation has been conducted in conjunction with this request for
a spinal cord stimulator trial. Therefore, we decided that the Plan does not have to pre-approve a spinal cord
stimulator trial (63650).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 21, 2021, to August 23, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says that payment is not allowed because we did not authorize the billed level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Specifically, the file shows that the admitting physician reasonably expected that the enrollee's necessary hospital care would span two midnights. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from August 21, 2021, to August 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Computed tomography (CT) scan (74176) provided on
October 10, 2021.
You asked the Plan to pay for code 74176. 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 74176
is a column II code to column I code 74177. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the Computed tomography (CT) scan (74176) provided on
October 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for substance abuse treatment facility care provided from October 19, 2020, to January 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for substance abuse treatment. You say that you have had treatment with this provider since 1986 and other patients at this provider continue to receive coverage. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and Medicare does not recognize a substance abuse treatment facility as an independent provider type.
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 substance abuse treatment facility care provided from October 19, 2020, to January 7, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950)
or pay more for the crown (D2740) provided on October 27, 2021.
You asked the Plan to pay for the core buildup and to pay more for the crown. You say that you did not want a
new tooth and feel you should not have to pay the $906.99 you are being charged. The Plan denied your
request. The Plan says core buildup is not a covered expense under your dental plan. The Plan also says that the
crown was processed according to the Plan's negotiated rate.
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, core buildup, including any pins when
required (D2950) is not among those covered under this benefit. The contract also clearly states that you are
responsible for a 70% coinsurance for the crown because it was rendered by an in-network provider. Therefore,
we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950)
or pay more for the crown (D2740) provided on October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140), panoramic x-ray (D0330), reline maxillary partial denture (D5740), and replace broken teeth (D5640) provided on May 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay more for the problem focused limited oral evaluation, panoramic x-ray, reline maxillary partial denture, and replace broken teeth. You say that you were not informed by the dental clinic that the dentist they assigned to render the services is not in the Plan's network. The Plan denied your request. The Plan says these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.
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, you are responsible for the difference
between the billed amount and allowed amount for covered dental services that are received OON. Therefore,
we decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140),
panoramic x-ray (D0330), reline maxillary partial denture (D5740), and replace broken teeth (D5640) provided
on May 5, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain
(70450) provided October 12, 2021.
You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed based
on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed with
an appropriate modifier as required by Medicare coding regulations.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450)
provided October 12, 2021.