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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle electromyography studies coded 51785 provided on January 8, 2021.
You asked the Plan to pay for the needle electromyography studies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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, the CPT Code Manual definition of code 51785 is needle electromyography studies (EMG) of anal or urethral sphincter, any technique. We find that CPT code 51785 is not supported in the medical record. Specifically, this code was billed with diagnosis code M43.07 (Spondylolysis, lumbosacral region). Diagnosis code M43.07 is not listed as a covered diagnosis code for this procedure code. Based on this information, we decided that Medicare rules for coverage of the needle electromyography studies have not been met. Therefore, we decided that the Plan does not have to pay for the needle electromyography studies coded 51785 provided on January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete lower denture (D5120) and complete upper denture (D5110).

You asked the Plan to pre-approve the dental services. You say that you have not received new dentures since 2008 or 2009 and your current dentures have been fixed 2 times. You need the new dentures to eat because you are unable to eat any solid foods. You did not receive new dentures in 2018. The Plan denied your request. The Plan says this request exceeds the benefit frequency limitation.

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. The records show that you received complete upper and complete lower dentures on January 12, 2018. Therefore, you are not eligible for a new set of dentures until after January 12, 2023. 

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 complete lower denture (D5120) and complete upper denture (D5110).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says medical studies have not proven that this service is helpful for treatment of the
health problem.
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 procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the procedure remains experimental for the treatment of back pain. More research is needed to
show safety and efficacy.
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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services after February 5, 2021.

You asked the Plan to pre-approve skilled nursing facility (SNF) services. You say that SNF admission was
medically necessary when it was requested. The Plan denied your request. The Plan says Medicare coverage
criteria were not met. 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 skilled nursing
facility (SNF) services after February 5, 2021. Maximus determined that the file does not show that a valid
NOMNC was delivered two or more days before February 5, 2021. The Plan requested a reopen and provided
the necessary notice documentation. Based on the medical records provided, as of the date in question, no
required skilled nursing services were identified. The documentation does not support that you required skilled
nursing or skilled therapy services daily in a skilled nursing facility on an inpatient basis after February 5,
2021. The documentation supports that you could safely be discharged to a lower level of care until weight-bearing
status was increased. Medicare criteria for continued SNF admission were not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of skilled nursing facility (SNF) services have not been met. Therefore, we
decided that the Plan does not have to pre-approve skilled nursing facility services after February 5, 2021.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to adjust the copayment from $40 to $20 for the home sleep study (G0399)
provided from March 19, 2021, through March 20, 2021.
You asked the Plan to adjust the copayment from $40 to $20. You say that you are requesting a reconsideration
of the Plan's denial for payment. The Plan denied your request. The Plan says that the copayment has been
applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay a $20 copayment for each in-network Medicare-covered
non-radiological diagnostic service. Examples include, but are not limited to electrocardiograms (EKG's),
pulmonary function tests, home or lab-based sleep studies, and treadmill stress tests.
The Plan says you must pay a $40 copayment for the home sleep study provided. Based on the Plan contract,
however, you cannot be asked to pay more than a $20 copayment for each sleep study. The Plan contract
indicates that a $20 copayment should be applied per service, and only a single service is documented. Without
evidence that two separate sleep studies were performed on the nights of March 19, 2021, through March 20,
2021, the application of two copayments is not supported. No reasonable person would think that a single sleep
study would apply two copayments just because it technically spans two calendar dates. Therefore, we decided
that the Plan has to adjust the copayment from $40 to $20 for the home sleep study (G0399) provided from
March 19, 2021, through March 20, 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: 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 the enrollee meets the full criteria for an inpatient acute rehabilitation stay. You say that the enrollee has been participating well in therapy and will benefit from continued physician oversight, 24-hour nursing supervision, and intense therapy to maximize functional independence. The Plan denied your request. The Plan says IRF care is not medically necessary. The Plan says that the enrollee could receive the help needed in another setting.
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 a stroke. 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 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 pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested monitor. The Plan denied your request. The Plan says you do not meet the criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation does not indicate that you perform blood glucose testing at least four times per day, use insulin with at least three daily injections, or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided on July 1, 2020, to July 13, 2020.

You asked the Plan to waive the copayment for SNF care. You say that the enrollee was discharged on July 13, 2020 and was moved to private home care. You also say you do not understand why the Plan has not paid the above room charges. The Plan denied your request. The Plan says the copayment the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $178 copayment per day, for days 1-20 for SNF care. The enrollee's contract with the Plan also clearly says that enrollees must pay a $178 copayment per day, for days 21-100 for SNF care.

The enrollee has been asked to pay a $178 copayment per day for SNF care. The records show that the enrollee received twenty-four (24) days of SNF care from June 19, 2020, to July 13, 2020. The records also show that the enrollee was charged a $0 copayment for days 1-20 and a $178 copayment for days 21-24. The enrollee's total cost-share is $712 ($178 x 4 days = $712). The EOC confirms that $178 is the correct copayment for this service. 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 skilled nursing facility (SNF) care provided on July 1, 2020, to July 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.

You asked the Plan to pre-approve a stair glide. You say that the enrollee has a hard time going down the stairs. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. 

While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary caridovascular screening (81404, 81401, 81403, 81405) provided on January 18, 2021.

You asked the Plan to pay for a hereditary caridovascular screening. You say that this is a Medicare-covered test. The Plan denied your request. The Plan says this is a screening test.

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 hereditary caridovascular 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 a hereditary caridovascular screening (81404, 81401, 81403, 81405) provided on January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical removal of erupted tooth (D7210) to be provided by an oral surgeon.

You asked the Plan to pre-approve the dental services. You say that you have an abscessed tooth and you need to have it taken care of. The Plan denied your request. The Plan says an extraction by an oral surgeon is not covered under the Plan benefits.

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. The health plan contract specifically says that services must be performed by a participating general dentist. 

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 removal of erupted tooth (D7210) to be provided by an oral surgeon.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is approved for spinal surgery. The requested bone marrow aspirate is considered experimental in nature, as more research is needed to show safety and efficacy. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on December 11, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit. You say that enrollees may obtain covered medical and behavioral health services at no greater cost to the enrollee than if the service was obtained from network providers and facilities, even if the provider is not a contracted provider. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.

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. The records provided for review do not show that the services at issue were urgent or emergent. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on December 11, 2020, by an out-of-network (OON) provider.
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 the enrollee meets the full criteria for an inpatient acute rehabilitation stay. You say that the enrollee can tolerate 3 hours of rehabilitation and the IRF level of care is more cost effective than a prolonged stay at a lower level of care. You say that IRF care is needed so that the enrollee can return home with the support of her family in a timely manner and avoid unnecessary hospitalizations. The Plan denied your request. The Plan says the guidelines for coverage of IRF care 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 surgical repair of a hip fracture after a fall. 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 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.