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

We decided that the Plan does not have to pay for laboratory testing provided on March 18, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab test. You say that the enrollee's treating physician requested that the sampled nodule be sent to you for testing. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.

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 testing provided on March 18, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided December 18, 2020.

You asked the Plan to pay for the full mouth debridement. You say that you received misinformation from the Plan and the services from this provider should be covered. The Plan denied your request. The Plan says a one-time exception has been made to process the services from this provider as in-network, however, the full mouth debridement is not a covered service 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 full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided December 18, 2020.
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 admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF
admission.

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 admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found based on the documentation
provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have
documented skilled therapy needs. The enrollee is ambulating household distances and tending to activities of
daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a
maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this
point are custodial and, as a practical matter, can be provided 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 admission to a SNF 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: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. 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 weakness and confusion and an ongoing infection of the spine. Medical conditions 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, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services.
You asked the Plan to pay for the paramedic intercept services. You say that this service was needed for
addition extensive care and was medically necessary. The Plan denied your request. The Plan says this item is
not a covered benefit.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances.
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as
defined above. It is noted that the only State in which these criteria are met is New York.
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the
paramedic intercept services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on August 4, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that the service was provided with no adequate time frame to obtain authorization. The Plan denied your request. The Plan says authorization for OON services 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services provided on August 4, 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 admission to a long term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to LTACH.

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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) for respiratory distress related to vocal cord dysfunction. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has been weaned from the ventilator and is not expected to be decannulated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. 

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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a second dental cleaning provided on December 15, 2020.

You asked the Plan to pay for this dental cleaning. You say that the Plan should pay for these dental services. The Plan denied your request. The Plan says dental cleanings are only covered once per year. Maximus overturned the Plans denial because records had not been submitted to show two cleanings were provided. The Plan requested a reopen and provided records to show you received a cleaning on June 11, 2020.

The Plan is correct in this case. Medicare does not cover dental services. In 2020, the Plan offered a dental benefit that exceeded Medicare coverage. For that reason, the Plan's coverage rules apply. The Plan contract is clear that only one cleaning is covered per year. That benefit was exhausted on June 11, 2020. This benefit was not available at the time of service. Therefore, we decided that the Plan does not have to pay for a second dental cleaning provided on December 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on September 3, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the claim submitted had a diagnosis code error. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan stated that the provider submitted this claim with a medical diagnosis, which was incorrect as the services rendered were a psychiatric evaluation. The Plan states psychiatric diagnosis codes should have been provided. The Plan states they requested a corrected claim and that once a correction is received with the updated diagnosis codes the submission would be reviewed.

The Plan is correct 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 codes. In this case, the claim was submitted with inappropriate diagnosis codes for the treatment provided. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity for the enrollee.
You asked the Plan to pre-approve Evenity. You say that Evenity is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Evenity. Our reviewer says that Medicare criteria are not met. Our physician reviewer found there is no literature that shows that the requested drug is therapeutically superior to the preferred first step agents. Medicare coverage 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 Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a positron emission tomography (PET) scan using Axumin (Fluciclovine F-18) for the enrollee.

You asked the Plan to provide coverage for the requested PET scan. You say that this imaging is medically necessary. The Plan denied your request. The Plan says the specific requested PET scan is not covered for newly diagnosed prostate cancer. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct Medicare criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that PET scans for initial treatment strategy of prostate cancer is a non-covered service. Therefore, we decided that the Plan does have to provide coverage for positron emission tomography (PET) scan using Axumin (Fluciclovine F-18) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on January 24, 2020.
You asked the Plan to pay for this service. 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.
Maximus overturned the Plans denial stating the enrollee was referred by a Plan provider. The Plan requested a reopen and stated that a non-participating provider submitted the lab work request. The records show the enrollee was not referred to this physician by a Plan provider.
The Plan is correct in this case. 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 Plan contract also states outpatient lab services may require prior authorization both in and out of network. The provider in this case is not a network provider with the Plan. The physician who ordered this lab work was not a provider with the Plan. The Plan did not pre-approve these lab services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for out of network lab services provided to the enrollee on January 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additional reimbursement for dental services provided out of network on November 3, 2020.

You asked the Plan to make additional payment for these dental services. You say that you believe the Plan should pay more of the amount you are being billed. The Plan denied your request. The Plan says the provider has been reimbursed the appropriate amount based on the Plan contract agreement. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct dental benefit. The Plan says that they paid 50% of the allowed amount for these dental services. The Plan also states this was an out of network provider who has overbilled you. Unfortunately, the Plan has no authority over non-contracted providers. The Plan states the records show the provider presented you with a pre-service agreement showing an estimated financial responsibility of $408.10. The records show you signed this agreement before receiving the dental services. The provider indicates they have now adjusted their bill to the agreed amount of $408.10.

The Plan is correct in this case. Medicare does not cover dental services. 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 the Plan has paid the appropriate amount to the out of network provider for the services rendered. Any further charges for these services that are in dispute are an issue between you and the provider. Therefore, we decided that the Plan does not have to pay additional reimbursement for dental services provided out of network on November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $65 copayment charged for urgent care services (including Covid-19 testing) provided on September 22, 2020.

You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the Plan contract and the claim submitted by your provider. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says that you must pay a $65 copayment for urgent care services. 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 $65 copayment charged for urgent care services (including Covid-19 testing) provided on September 22, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction and waive the copayment for a comprehensive eye exam provided on August 17, 2020.
You asked the Plan to pay for an eye refraction and waive the copayment for a comprehensive eye exam. The Plan denied your request. The Plan says that the correct copayment for the comprehensive eye exam has been applied to the claim. The Plan also says you have exceeded the Plan benefit for an eye refraction. The Plan covered an eye refraction on November 16, 2020.
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 $40 copayment for Medicare Covered Vision Services, Specialist Office.
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules You have been asked to pay $40 copayment for the comprehensive eye exam. The comprehensive eye exam falls within the Medicare Covered Vision Services, Specialist Office benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a comprehensive eye exam provided on August 17, 2020.
The file shows that the Plan covered an eye refraction on November 16, 2020 and you have exceeded the Plan's benefit limit of one routine eye refraction. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, the Plan does not have to pay for an eye refraction provided on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided from January 4, 2021, through January 22, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were not notified for the facility charge and two (2) separate dates for check-up. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received specialist office services on January 22, 2021. You were asked to pay
a $45 copayment for the services. Your 2021 EOC states that enrollees must pay a $45 copayment for each Medicare-covered specialist visit. 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 the specialist office visit provided from January 4, 2021, through January 22, 2021.