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

We decided that the Plan does not have to pre-approve a chemotherapy regimen of paclitaxel, carboplatin, and Keytruda.
You asked the Plan to pre-approve paclitaxel, carboplatin, and Keytruda. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this chemotherapy combination is correct, because this combination is not supported by the Food & Drug Administration (FDA) and is only indicated in metastatic non-small cell lung cancer stages 1 to 2.
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 paclitaxel, carboplatin, and Keytruda. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested chemotherapy regimen. Our physician reviewer found this combination of paclitaxel, carboplatin, and Keytruda is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. There is no information on staging to indicate if this is indicated. The requested use is not supported by major drug compendia or by research appearing in a Medicare-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of paclitaxel, carboplatin, and Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve a chemotherapy regimen of paclitaxel, carboplatin, and Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the complete series x-ray (D0210), and the extraction (D7210) provided on November 21, 2019.
You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that you could not email or fax your request for reimbursement, and it would only be accepted by mail. You say that you mailed the request for reimbursement on October 15, 2020. You also say that the mail must have been delayed due to the presidential election. The Plan denied your request. The Plan says claims must be filed within 365 days of the date of service in order to be considered for coverage.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the dental services was not filed until December 15, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the complete series x-ray (D0210), and the extraction (D7210) provided on November 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for foot orthotics. You say that you were under the assumption this service would be covered with a coinsurance. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 3, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. 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 above, 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 provided on December 3, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payments for the CT scan and surgical procedure provided from August 19, 2020 to August 23, 2020.

You asked the Plan to waive the co-payments for the CT scan and surgical procedure. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a CT scan and a surgical procedure in an outpatient hospital facility on the dates of service at issue in this appeal. The Plan says that the correct co-payments have applied per your contract with the Plan.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 co-payment for each Medicare-covered advanced imaging service and a $325 co-payment for outpatient surgery provided in an outpatient hospital facility.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a CT scan and a surgical procedure during your outpatient hospital stay from August 19, 2020 to August 23, 2020. You have been asked to pay a $225 co-payment for the CT scan. The CT scan falls within the Outpatient diagnostic tests benefit category. You have been asked to pay a $325 co-payment for the surgical procedure. The surgical procedure falls within the Outpatient surgery benefit category. This means that you have been asked to pay the correct amounts 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 co-payments for the CT scan and surgical procedure provided from August 19, 2020 to August 23, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychotherapy visit provided on September 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you were not provided with an adequate time frame to obtain authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 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 a psychotherapy visit provided on September 11, 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 a resin-based filling for a back tooth (D2394) provided on November 19, 2020.
You asked the Plan to pay for the resin-based filling. You say that you were in severe pain and could not wait to have these services done. You cannot afford these services. The Plan denied your request. The Plan says resin-based fillings for back teeth are not covered by the Plan's supplemental dental benefit. Resin-based fillings can only be covered for anterior (front) teeth. Back teeth should be provided with silver (amalgam) fillings.
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 a resin-based filling for a back tooth (D2394) provided on November 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen concentrator (E1390) provided on September 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the oxygen concentrator. You say that you had a prescription for the item. The Plan denied your request. The Plan says Inogen is an out of network provider, and therefore not covered.
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 oxygen concentrator (E1390) provided on September 11, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reprocess the copayment for the inpatient rehabilitation services
provided from June 26, 2020, to July 20, 2020.
You asked the Plan to reprocess the copayment for the inpatient rehabilitation services. You say that you
believe the claim should be reduced. The Plan denied your request. The Plan says the claim has processed
correctly, and no reimbursement is due.
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 $325
copayment per day, days 1-5 and a $0 copayment for additional hospital days. for inpatient hospital care.
You have been asked to pay a total cost share of $1625 for the inpatient rehabilitation services ($325
copayment x 5 days). The inpatient rehabilitation services falls within the inpatient hospital 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 reprocess the copayment for the inpatient rehabilitation services
provided from June 26, 2020, to July 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care beyond December 9, 2020.

You asked the Plan to pre-approve inpatient psychiatric care beyond December 9, 2020. You say that inpatient admission 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 inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care. Our physician reviewer found based on the medical records provided, the criteria for continued acute inpatient mental health treatment for December 9, 2020 forward were not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care beyond December 9, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 23, 2020,
through October 27, 2020.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that
based on the clinical records provided, this enrollee's care did not meet medical necessity criteria for an acute
inpatient hospital level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found that the enrollee was a then, a 91-year-old male with history of CVA, HTN and DM who was
presented to the Emergency Department (ED) on October 23, 2020, with right sided flank pain radiating down
his leg. In the ED, the enrollee was afebrile with stable vital signs and with some hypertension noted. From the
records received there were no new neurologic deficits, no chest pain or respiratory issues. All imaging
including CTH, CT chest and abdomen were negative for an acute pathology. BP control and observation
continued. He remained hemodynamically stable throughout the observation period as reflected in the
documentation. His condition stabilized and improved, and he was discharged home on October 27, 2020,
when considered medically stable. The review has determined that the record showed that at the time of
inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care
(including earlier ED and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from October 23, 2020, through October 27, 2020.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for abdominal ultrasound (CPT code 76700)
provided on May 22, 2019.
You asked the Plan to waive the copayment for the abdominal ultrasound. You say that the claim was
processed accordingly with your 2019 EOC benefits. The Plan states per review of the call history there was no
indication that you contacted the plan prior to verify benefits, and no misinformation was provided by the plan.
The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC
benefits. The Plan states per review of the call history there was no indication that you contacted the plan prior
to verify benefits, and no misinformation was provided by the plan.
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 an abdominal ultrasound (CPT code 76700) on May 22, 2019. You
were asked to pay a $50 copayment for the ultrasound. Your 2019 EOC states that enrollees must pay a $50
copayment for all other diagnostic tests. 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 abdominal
ultrasound (CPT code 76700) provided on May 22, 2019.
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 these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 surgical repair of a hip fracture. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the continued SNF stay provided from November 16, 2020,
to December 15, 2020.
You asked the Plan to pay for the continued SNF stay. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee
required no nursing services which would be considered skilled services by Medicare.
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 continued SNF stay. Our reviewer says
that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did
not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill,
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing
and/or skilled therapy on an inpatient basis in a SNF 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 continued SNF stay have not been met. Therefore, we decided that the Plan
does not have to pay for the continued SNF stay provided from November 16, 2020, to December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay a 50% coinsurance for the endodontic therapy. We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, or pay more than a 50% coinsurance for the endodontic therapy.

You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and endodontic therapy. You say that you believe you should be reimbursed for these services because you were referred to this provider, and did not know they were an opt out provider. The Plan says that these services were rendered by a provider who has opted out of the Medicare program, and you were referred by an out-of-network provider. The Plan also says that paying Medicare-eligible claims for services provided by a provider that opted out of Medicare is prohibited.

We decided that the Plan has to pay a 50% coinsurance for the endodontic therapy.

The Plan follows Medicare rules. Medicare rules say that the health plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits.

You received endodontic therapy, which is an endodontic service. The contract lists endodontics as a covered comprehensive dental service, and you are responsible for a 50% coinsurance. The EOC does not clearly state that endodontic therapy is not a covered service, and you reasonably believed this service would be covered by the Plan at 50%. Therefore, we decided that the Plan has to pay a 50% coinsurance for the endodontic therapy.

We also decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, or pay more than a 50% coinsurance for the endodontic therapy.

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 problem focused limited oral evaluation and first intraoral periapical x-ray are not among those covered under this benefit. The contract also says that you are responsible for a 50% coinsurance for comprehensive dental services including endodontics. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, or pay more than a 50% coinsurance for the endodontic therapy.

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.