Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for an ergonomic wheelchair (K0001) purchased on January 29,
2021.

You asked the Plan to pay for this wheelchair. You say that you have Parkinson's and needed a more
comfortable wheelchair. You say that your doctor wrote you a prescription for an ergonomic wheelchair which
you purchased that meets your comfort needs. The Plan denied your request. The Plan says based on a phone
call with your physician's office on April 6, 2021, it was stated your husband contacted the physician's office
after the wheelchair was purchased. It was stated that you purchased the wheelchair on your own without
referral. The Plan also confirmed the provider you purchased the wheelchair from is not a Medicare eligible
durable medical equipment provider.

Maximus reviewed the case and upheld or agreed with the Plan's denial. You requested an ALJ hearing. The
ALJ remanded the case back to Maximus for a reopen or second review and for clarification.

The rules say a plan must disclose to its enrollees in clear, accurate terms all coverage requirement and
information. Your contract with the Plan clearly says that durable medical equipment typically rented will not
be approved for full purchase. Your contract also clearly states enrollees must use Medicare eligible providers
when obtaining care or equipment. The Plan has confirmed with your physician that you did not follow the
rules required by your Plan contract to allow coverage. Your physician did not refer you to this provider. This
provider is not a Medicare eligible provider. Wheelchairs have specific coverage criteria that require review
before they are issued for coverage. Upon second review we find you did not follow the rules clearly stated in
your Plan contract for obtaining durable medical equipment. Therefore, it remains our decision that the Plan
does not have to pay for an ergonomic wheelchair (K0001) purchased on January 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met because the requested level of care is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that the enrollee is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunization administration of the Zoster vaccine provided on April 9, 2021.
You asked the Plan to pay for the immunization administration (90471). You say that you would like the Plan to pay this claim. The Plan denied your request. The Plan says the administration of a vaccine is not covered when the vaccine itself is not covered. The Zoster vaccine is not covered under your Medicare Part B benefit.
Medicare Part B does not pay for or provide the Zoster vaccine. The Plan follows the same rules. Therefore, we decided that the Plan does not have to pay for the immunization administration of the Zoster vaccine provided on April 9, 2021.
Benefits for the immunization administration (90471) 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364) provided May 6, 2021.

You asked the Plan to pay for the cone beam CT scan. You say that you believed your dental benefit would apply towards the services and did not know the provider was out-of-network. The Plan denied your request. The Plan says the claim has been reprocessed to cover services as in-network however the cone beam CT scan is not covered under your 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.

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 pay for the cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364) provided May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on April 7, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for podiatry services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is also out-of-network.

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 podiatry services provided on April 7, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on June 30, 2020.

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 codes 95938 and 95908 are not supported.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The file shows that procedure codes 95938 (short-latency somatosensory evoked potential study) and 95908 (nerve conduction studies, 3-4 studies) were billed with POS code 15 for a mobile unit; however, the records show that the services were performed in a facility setting. Therefore, we decided that the Plan does not have to pay for the testing services rendered on June 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services rendered on May 13, 2020.
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 codes 70547, 70551, 71260, 70450, and 71045 are 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 70547 is magnetic resonance angiography, neck; without contrast material(s). The definition of code 70551 is magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material. The definition of code 71260 is computed tomography, thorax, diagnostic; with contrast material(s). The definition of code 70450 is computed tomography, head or brain; without contrast material. The definition of code 71045 is radiologic examination, chest; single view.
We find that procedure codes 70547, 70551, 71260, 70450, and 71045 are not supported in the medical record. Specifically, there is no documentation of MRA of the neck to support code 70547. There is no documentation of MRI of the brain to support code 7051. There is no documentation of CT thorax to support code 71260. There is no documentation of CT head/brain to support code 70450. There is no documentation of a chest x-ray to support code 71045.
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 imaging services rendered on May 13, 2020.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the members acute and chronic medical conditions
require medically necessary physician over site on a daily basis to monitor and manage his various medical
comorbidities. The Plan denied your request. The Plan says that the patient would not benefit from an intensive
rehabilitation program, does not meet the level of complexity for medical management needs, and does not
require supervision by a rehabilitation physician.

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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for altered mental status
and falling episodes. The enrollee's medical problems are stable. There are no complex nursing or
rehabilitation needs. The patient 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 an intensive,
multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.

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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical nutrition therapy services

You asked the Plan to pay for medical nutrition therapy services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee does not meet criteria.

The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. 

Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for the medical nutrition therapy services
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided from July 6, 2020, through September 24, 2020.

You asked the Plan to pay for the laboratory services. You say that the charges are for Coronavirus (COVID-19) testing and are not related to hospice care. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided from July 6, 2020, through September 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continued SNF services provided from March 26, 2021, through April 24, 2021.

You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says continuation of SNF care is not medically necessary.

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 pay for SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and effectively provide medically necessary and reasonable treatment. This enrollee did not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services were not required. As a practical matter, this enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear custodial in this case from March 26, 2021 through April 24, 2021. 

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 pay for continued SNF services provided from March 26, 2021, through April 24, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on April 24, 2021.

You asked the Plan to pay for lab testing. You say that this testing is covered by Medicare and was medically necessary. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because prior authorization was denied for this testing.

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 Plan did not provide the applicable Evidence of Coverage (EOC) for this contract and date of service. Without this information, we cannot determine whether this health plan contract had any network lock-in or prior authorization requirements that apply to this service. Furthermore, the Plan did not provide any evidence that prior authorization was denied for this testing. Therefore, the Plan has not shown that its decision to deny payment is correct or justified according to Medicare rules and the enrollee's contract with the Plan. Therefore, we decided that the Plan has to pay for laboratory testing provided on April 24, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the E2313 harness, E2377 expandable controller and E2311 electronic connection, for the enrollee.

You asked the Plan to pre-approve a power wheelchair and several accessories for the enrollee. You say that the requested power wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says while the power wheelchair and Medicare allowed accessories were approved, codes E2313 harness, E2377 expandable controller and E2311 electronic connections are not covered in this case.

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 accessories in question. Our physician reviewer found the requested items exceed the enrollee's medical need. The documentation does not show the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength in the left upper extremity and function supports that the patient can control any power options through their own individual switches. Medicare criteria are 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 the denied accessories are not met.

Therefore, we decided that the Plan does not have to pre-approve the E2313 harness, E2377 expandable controller and E2311 electronic connection, for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 13, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the 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 was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses provided on March 24, 2021.

You asked the Plan to pay for the lumbar-sacral orthosis (L0648), knee orthoses (L1851) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says reasonableness of the provided durable medical equipment is not established.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery or relevant medical records which support medical necessity for the supplies provided in this case. According to the file the physician ordered knee orthoses L1833 and lumbar-sacral orthosis L0635. The claim and proof of delivery are for L0648 and L1851. Therefore, we decided that the Plan does not have to pay for the orthoses provided on March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intermittent limb compression device and accessories.

You asked the Plan to pay for the intermittent limb compression device and accessories. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the medical records do not support the services as billed.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. In this case, the medical records do not support that the need for the purchased medical equipment was discussed with the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the intermittent limb compression device and accessories.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the femur x-ray provided on May 4, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered 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. 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 the femur x-ray provided on May 4, 2021 by an out-of-network (OON) provider.