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

We decided that the Plan does not have to pay for lab tests provided on February 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 lab tests provided on February 7, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on December 13, 2020 by an OON provider.
You asked the Plan to pay for the home visit. You say that urgent/emergent care was provided, which does not require prior authorization. The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.
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 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 home visit provided on December 13, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified maxillofacial prosthesis, by report (D5999) provided December 14, 2020.
You asked the Plan to pay for the unspecified maxillofacial prosthesis. You say that it isn't right that the service is being denied based on the procedure code and it should be covered. The Plan denied your request. The Plan says the separate laboratory fee is not a covered benefit and since the provider is not contracted with the Plan, they do not have any control of how the provider bills for services.
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 unspecified maxillofacial prosthesis, by report (D5999) provided December 14, 2020.
Your complaint about how the services were processed by the Plan for coverage based on the dental bill is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient mental health care stay provided from January 18, 2021, to January 22, 2021.
You asked the Plan to waive the copayment for an inpatient mental health care stay. You say that you disagree with the charges due to the quality of care received. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $250 copayment for days 1-6 for inpatient mental health care. You had an inpatient mental health care stay from January 18, 2021, to January 22, 2021. Therefore, you are responsible to pay a $250 copayment for days 1-4 (January 18, 2021, to January 21, 2021). $250 (copayment) x 4 (inpatient days) = $1,000. You have been asked to pay the total copayment amount of $1,000 an inpatient mental health care stay. An inpatient mental health care stay falls within the inpatient mental health care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient mental health care stay provided from January 18, 2021, to January 22, 2021.
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bandages and dressings (A6252, A6446, A6454) for wound care provided on December 15, 2020, by an OON provider.
You asked the Plan to pay for bandages and dressings for wound care. You say that the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for OON care have not been met.
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 bandages and dressings (A6252, A6446, A6454) for wound care provided on December 15, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on November 5, 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 code 99153 is not separately payable.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. We looked at the file and Medicare rules. Billed procedure code 99153 (moderate sedation services) has a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on November 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 88104, 88305, 88312, and 88361 provided on November 12, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 88104, 88305, 88312, and 88361 are not supported in the medical record. Specifically, these services require the modifier 26. In addition, the services were not furnished on the facility claim; however, the global diagnostic service was not within the same Medicare Physician Fee Schedule (MPFS) payment locality. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 88104, 88305, 88312, and 88361 provided on November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92004) and refraction (92015) provided on
January 8, 2021.
You asked the Plan to pay for the vision services. You say that you were not supposed to be billed for these
services as they are covered. The Plan denied your request. The Plan says this claim needs to be submitted to
the supplemental vision vendor directly and not to the Plan. Routine vision services are not covered by Original
Medicare but can be covered by the supplemental vision benefit. Contact information and instructions for
submitting this claim to the correct entity were included in the decision letter.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services through a supplemental routine vision provider.
We looked at the file and the Plan's rules. This claim needs to be submitted directly to the vision benefit
provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have
not been met. Therefore, we decided that the Plan does not have to pay for an eye exam (92004) and refraction
(92015) provided on January 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit and office visit provided by an out-of-network provider on December 10, 2020.
You asked the Plan to pay for the annual wellness visit and office visit. You say that a referral and authorization should not be required. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.
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 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 annual wellness visit and office visit provided by an out-of-network provider on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on January 13, 2021.
You asked the Plan to pay for the periodontal maintenance. You say that you were not told that this service was not covered under your insurance. The Plan denied your request. The Plan says this service is not covered.
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 periodontal maintenance provided on January 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the abdomen and pelvis (74174).

You asked the Plan to pre-approve a CTA of the abdomen and pelvis. You say that this service is medically necessary. The Plan denied your request. The Plan says this specific imaging service would not be more helpful for the enrollee's condition than a CT scan.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.

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 a CTA of the abdomen and pelvis. Our reviewer says that the requested service is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 67-year-old female with a history of pancreatic neuroendocrine tumor. She had a CTA of the abdomen and pelvis done in 2019 for purposes of surgery preparation. Based on the oncology imaging guidelines, CTA of the abdomen/pelvis is not medically necessary for monitoring or surveillance of any disease progression. The medical records do not indicate or support the use of CTA over CT of abdomen and pelvis for this purpose. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CTA of the abdomen and pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the abdomen and pelvis (74174).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on January 22, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you were told that you would be reimbursed for these services. The Plan denied your request. The Plan says these services are not covered. 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, 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 problem focused limited oral evaluation and first intraoral periapical x-ray provided on January 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says rules for SNF care have 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 that the member has stabilized medically and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The member does not have any parental medication; complex wound care or nutrition given via a feeding tube. He is medically stable without any acute exacerbations of chronic medical problems. His physical function is at or near his baseline and he can receive services at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray (D0220) and unspecified preventative procedure (D1999) provided on December 30, 2020 and extraction (D7140) provided on January 4, 2021.

You asked the Plan to pay for the dental services. You say that these services were medically necessary, and you did not realize you needed to check the participation status of a provider. The Plan denied your request. The Plan says services received from providers who have chosen to opt out of Medicare cannot be covered.

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 Plan's rules state that no payment can be made for services received from a provider who has opted out of Medicare.

Though the Plan offers a dental benefit in excess of Medicare coverage, services received from a provider who has opted out of Original Medicare are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the x-ray (D0220) and unspecified preventative procedure (D1999) provided on December 30, 2020 and extraction (D7140) provided on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fixed partial denture sectioning provided on January 18, 2021.

You asked the Plan to pay for the fixed partial denture sectioning. You say that this procedure was necessary. The Plan denied your request. The Plan says this service is not covered under your 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 pay for the fixed partial denture sectioning provided on January 18, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continued skilled nursing facility services from August 14, 2020, to September 12, 2020.

You asked the Plan to pay for the skilled nursing facility (SNF) services. You say that the enrollee needed SNF services after August 13, 2020. The Plan denied your request. The Plan says there was no daily skilled nursing or therapist need on the dates of service in this case.

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 the skilled nursing facility (SNF) services. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs.

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 the skilled nursing facility (SNF) services have not been met. Therefore, we decided that the Plan does not have to pay for continued skilled nursing facility services from August 14, 2020, to September 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a superion interspinous spacer device.

You asked the Plan to pre-approve a superion interspinous spacer device. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is considered experimental and investigational.

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 a superion interspinous spacer device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested superion spacer device is experimental. More research is needed to show safety and efficacy of the device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a superion interspinous spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve a superion interspinous spacer device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for eye surgery services provided on July 19, 2019, by an OON provider.
You asked the Plan to pay for eye surgery services. You say that the requested services were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for OON care have not been met.
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 eye surgery services provided on July 19, 2019, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).

You asked the Plan to pre-approve Injection, pembrolizumab, 1 mg (J9271).. You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says the enrollee does not meet clinical criteria for coverage.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Injection, pembrolizumab, 1 mg (J9271). Our reviewer says that the drug is not medically necessary. Our physician reviewer found the patient had progression of disease on previous pembrolizumab. The use of this drug is not supported by the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not supported or recommended in any of the compendia. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injection, pembrolizumab, 1 mg (J9271) have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271).