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

 We decided that the Plan does not have to pay for the surgical services rendered on February 9, 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 23600 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 23600 is closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation.  We find that CPT code 23600 is not supported in the medical record. Specifically, there is no documentation of closed treatment of a proximal humeral fracture without manipulation. 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 surgical services rendered on February 9, 2021.
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 services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF.  As a practical matter you do not require the necessary services on 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services rendered from November 1, 2020, to November 16, 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 submitted records do not support the billing of secondary diagnosis code J95.1.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with secondary diagnosis code J95.1 (postoperative pulmonary insufficiency following thoracic surgery). 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 these services. Our reviewer says that the submitted records do not support the billing of secondary diagnosis code J95.1. Our physician reviewer found while acute postoperative pulmonary insufficiency was documented in the progress notes and discharge summary, other provider documentation was unclear and incomplete regarding this condition. The documentation indicated successful weaning from mechanical ventilation and extubation to low flow supplemental oxygen via nasal cannula on the day of surgery. However, in this case, a past medical history of chronic pulmonary conditions requiring low flow supplemental oxygen past a 72-hour time frame following major thoracic surgery without evidence consistent with respiratory distress would not be consistent with the condition of acute postoperative pulmonary insufficiency. The billing of secondary diagnosis code J95.1 is therefore not supported.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from November 1, 2020, to November 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an x-ray of the chest (71046) rendered on August 13, 2021.  You asked the Plan to waive the copayment for an x-ray of the chest. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for each x-ray service.   You have been asked to pay a $10 copayment for an x-ray of the chest. X-rays of the chest fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an x-ray of the chest (71046) rendered on August 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Flow cytometry, interpretation (88189) provided December 14, 2020.  You asked the Plan to pay for code 88189. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says diagnosis code D63.1 is not a covered diagnosis code for code 88189 per Medicare guidelines.    The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file, the Plan's contract and Medicare rules. Medicare has limited ICD-10-CM codes that support medical necessity and provide coverage for CPT code 88189. Diagnosis code D63.1 as billed in this case is not a covered diagnosis code per Medicare guidelines. Therefore, we decided that the Plan does not have to pay for the Flow cytometry, interpretation (88189) provided December 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for critical care services provided in an inpatient acute hospital setting (99291) from May 8, 2021, to May 11, 2021.   You asked the Plan to waive the deductible for inpatient hospital care. You say that you are on a fixed income and cannot cope with all of the charges. You also say the services received were related to your contraction of the COVID-19 virus. You requested for the charges to be adjusted. The Plan denied your request.   The Plan says you had not reached your deductible at the time of service and therefore, the charges were applied as member liability. Additionally, the Plan says the COVID-19 testing and treatment coverage guidelines clearly state that cost-sharing for COVID-19 treatment is applied according to the Member's benefit package. The Plan further states you will be responsible for any copayment, coinsurance, deductible, or out-of-network costs under this guidance, which can be found on the Plan's website. The Plan also references Medicare rules regarding items and services related to COVID-19 which indicate you are still responsible for any hospital deductible, copayment, or coinsurance that applies.   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 there is a $500 deductible which applies to Inpatient Hospital care.   The item or service you asked the Plan to waive the deductible for falls within the Inpatient Hospital care benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to Inpatient Hospital care. This cost sharing is a contractual obligation that had not been met at the time inpatient hospital services were received on May 8, 2021, to May 11, 2021. Therefore, we decided that the Plan does not have to waive the deductible for critical care services provided in an inpatient acute hospital setting (99291) from May 8, 2021, to May 11, 2021.   For date of service May 11, 2021, you were only asked to pay $33.54. At this point, your $500 deductible had been met, therefore the Plan paid for the remainder of the cost.   Your complaint about a potential quality of service issue 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. The Plan indicated in the case narrative to Maximus that a grievance regarding this complaint has been filed and will receive a separate outcome. The Plan did not disclose the result of this grievance. Please contact the Plan with questions regarding your complaint.
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 services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. Your refusal to participate in skilled therapy does not support that you require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter you do not require the necessary services on 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 shingles vaccine rendered on July 22, 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 the services are not covered.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the shingles vaccine rendered on July 22, 2021.   Benefits for these services 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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical therapy services rendered on October 28, 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 were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that outpatient rehabilitation claims must be billed with the GN, GO, or GP modifier.  We looked at the file and Medicare rules. The file shows that procedure code G0283 (electrical stimulation) was not billed with the required GP modifier. 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 physical therapy services rendered on October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prolotherapy provided on February 3, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.  The Plan must follow Medicare rules. Medicare rules say that the medical effectiveness of prolotherapy has not been verified by scientifically controlled studies. Accordingly, reimbursement for this modality should be denied on the ground that they are not reasonable and necessary as required by ?1862(a)(1) of the Act.             We looked at the file and Medicare rules. Per NCD 150.7, the requested prolotherapy is not a covered service. 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 the prolotherapy provided on February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the routine foot care rendered on July 19, 2021 to August 3, 2021.  You asked the Plan to pay for these services. You say that you have callouses on the balls of your feet. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails.   Records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. 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 routine foot care rendered on July 19, 2021 to August 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 16, 2021.  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 progress notes were not submitted that are needed to determine the clinical utility of this testing.  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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that four attempts were documented to obtain the ordering provider's progress notes. These notes are needed in order to determine the clinical utility of the testing. The review has determined that the enrollee does not meet the criteria for this testing.  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 drug testing services provided to the enrollee on March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the electrical connection (E2311).  You asked the Plan to pre-approve the electrical connection. You say that the item is medically necessary. The Plan denied your request. The Plan says Although there are two approved power options on this wheelchair (power tilt and center mount power elevating leg rest/platform), there is not a medical need to control these power options through the joystick.  The Plan follows Medicare rules. Medicare rules say that codes E2310 and E2311 describe the electronic components that allow the beneficiary to control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or non-proportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, power seat elevation, power standing. It includes a function selection switch which allows the beneficiary to select the motor that is being controlled and an indicator feature to visually show which function has been selected. When the wheelchair drive function has been selected, the indicator feature may also show the direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate display box or may be integrated into the wheelchair interface. Payment for the code includes an allowance for fixed mounting hardware for the control box and for the display box (if present).  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 electrical connection. Our reviewer says that the service is not medically necessary Our physician reviewer found you have adequate upper extremity strength and range of motion to control the wheelchair's power options with their own switches.  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 electrical connection have not been met. Therefore, we decided that the Plan does not have to pre-approve the electrical connection (E2311).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.  You asked the Plan to pre-approve SNF services. You say that this is the level of care required for the enrollee to safely be discharged at the current level of care. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or at the home with home health care services.  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 that the enrollee's condition does not meet Medicare criteria for SNF services.  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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on August 24, 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 were not billed correctly.  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 claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for medical services provided to the enrollee on July 2, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  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 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 medical services provided to the enrollee on July 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the enrollee on July 19, 2021.  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 an appropriate modifier was not billed in this case.  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 imaging services (procedure code 70450) provided to the enrollee on July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (80307, 83789, G0480) provided on June 21, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for laboratory services. You say that most in-network providers cannot provide these services. The Plan denied your request. The Plan says these services were not authorized.  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 laboratory services (80307, 83789, G0480) provided on June 21, 2021, by an out-of-network (OON) provider.