Persius/hicric huggingface dataset:
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 IRF services would benefit your recovery. The Plan denied your request. The Plan says the requested level of care is not medically necessary.
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. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve lumbar fusion surgery.

You asked the Plan to pre-approve lumbar fusion surgery. You say that it is medically necessary to receive this
surgery immediately to prevent permanent neurological dysfunction. The Plan denied your request. The Plan
says that the criteria for lumbar fusion surgery have not been met.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. In this case, it appears that most of the case file was not submitted. We requested
that the Plan resend a copy of the complete case file. Crucially, there were no medical records included in the
request we received. A response to our request was not received. Therefore, we decided that the Plan has to
pre-approve lumbar fusion surgery.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $275 copayment charged for ambulance transport provided on February 1, 2020.
You asked the Plan to waive this copayment. You say that you do not owe this copayment because you believe you met your maximum out of pocket for 2020. The Plan denied your request. The Plan says at the time of service you had not met your maximum out of pocket and that claim would have been figured into your total as the Plan year progressed. Maximus overturned the Plans denial because the Plan did not submit your claim information. The Plan has since submitted your claim information and we reopened this case.
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 (such as copayments, deductibles and coinsurance). You had not met your maximus out of pocket at the time this service was rendered. 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 $275 copayment charged for ambulance transport provided on February 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit and diagnostic testing provided by a participating provider on December 21, 2020.
You asked the Plan to waive the copayment for a specialist office visit and diagnostic testing. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayments have been applied.
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 $35 copayment for physician/practitioner services/in-network/specialist and a $95 copayment for outpatient diagnostic tests/in-network/diagnostic tests. You have been asked to pay a $35 copayment for a specialist office visit. You have been asked to pay $55.16 which is less than your copayment amount of $95 copayment for diagnostic testing. The total amount you are being asked to pay is $90.16 ($35 + $55.16 = $90.16). A specialist office visit falls within the physician/practitioner services/in-network/specialist benefit category. Diagnostic testing falls within the outpatient diagnostic tests/in-network/diagnostic tests 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 specialist office visit and diagnostic testing provided by a participating provider on December 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided a participating provider on March 8, 2021.

You asked the Plan to waive the copayment for a CT scan. You say that this should be included in the surgery price. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $100 copayment for outpatient diagnostic tests/ultrasound. 

You have been asked to pay a $100 copayment for a CT scan. Since a CT scan was provided, the correct copayment has been applied. A CT scan falls within the outpatient diagnostic tests/ultrasound 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 CT scan provided a participating provider on March 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the enrollee has suffered from this condition for too long and has greatly impacted their quality of life. The Plan denied your request. The Plan says the services are 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 the surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex 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 the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on January 26, 2021 to February 24, 2021.
You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says no referral was received for these services from the enrollee's primary care doctor.
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 services at issue in this appeal. The Plan did not pre-approve the service
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 home health services provided on January 26, 2021 to February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an automatic external defibrillator provided on August 5, 2020, by an out of network (OON) provider.

You asked the Plan to pay for the automatic external defibrillator provided OON. You say that The Plan denied your request. The Plan says the services in dispute were not urgent or emergent, nor were they 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 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 an automatic external defibrillator provided on August 5, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your podiatrist has recommended orthotics. 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 pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) for tooth #2, abutment crowns (D6740) for tooth #'s 2 and 5, and pontics (D6245) for tooth #'s 3 and 4.
You asked the Plan to pre-approve the core buildup, abutment crowns, and pontics. You say that you are on a limited income, and cannot afford to pay for these services. The Plan denied your request. The Plan says there is not enough bone around tooth #2 for a core buildup. The Plan says that bridges are only covered to replace one anterior tooth. The Plan also says that pontics are not covered under your benefit 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. The Plan covers the core buildup, abutment crowns, and pontics when the services are medically necessary and reasonable. 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 core buildup, abutment crowns, and pontics. Our reviewer says that the bridge from tooth #'s 2 to 5, core buildup, and abutment crowns do not meet the Plan criteria for coverage. Our physician reviewer found tooth #2 has an existing restoration that appears intact. There would not be a need for a core restoration on any tooth that is not being prepared for a crown, and in this case the requested bridge is not a covered service. If the tooth were to be prepared for a crown or bridge abutment, there is sufficient structure remaining such that a core buildup would not be necessary even if a crown or bridge abutment were to be pursued. Our reviewer found that abutment crowns are only properly coded as such when the crowns are connected or as part of a bridge with connected pontics. In this instance as the requested bridge is not a covered service, the abutments on #2 and #5 are also not to be considered a covered service. Our physician reviewer also found that if individual crowns were requested instead, these also would not be necessary as there is insufficient missing tooth structure to require a crown restoration on either of the teeth. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the core buildup, abutment crowns, and pontics have not been met. Therefore, we decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) for tooth #2, abutment crowns (D6740) for tooth #'s 2 and 5, and pontics (D6245) for tooth #'s 3 and 4.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain management services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve OON services. You say that you need pain management before your knee surgery. The Plan denied your request. The Plan says there are in-network providers available who can supply the requested service.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve pain management services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 4, 6, 9, and 10 and retainer crowns (D6750) for tooth #'s 5, 7, and 8.
You asked the Plan to pre-approve the pontics and retainer crowns. You say that you are in urgent need of the bridge because you are in pain and unable to eat. The Plan denied your request. The Plan says these services are not medically necessary.
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 covers the pontics and retainer crowns when the services are medically necessary and reasonable. 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 pontics and retainer crowns. Our reviewer says that due to there being multiple areas that have missing teeth, the Plan provisions are not met. Our physician reviewer found there are multiple missing posterior teeth as well as multiple missing anterior teeth. Our reviewer found that there has been no documentation supplied that indicates a physical or neurological disorder that precludes the use of a removable appliance. Our physician reviewer also found that given the Plan limitations on fixed appliances, there would be no medical necessity for the requested bridgework. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the pontics and retainer crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 4, 6, 9, and 10 and retainer crowns (D6750) for tooth #'s 5, 7, and 8.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neupogen (J1442).

You asked the Plan to pre-approve neupogen. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage has not been met.

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 neupogen. Our reviewer says that the requested drug, neupogen, is not medically necessary. Our physician reviewer found neupogen is not FDA-approved for the enrollee's diagnosis. The reviewer found that the requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS approved medical journal. Therefore, the reviewer found that the requested drug is not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neupogen have not been met. Specifically, the requested use of this drug is not indicated by any of the major drug compendia or clinical research that appears in a CMS approved medical journal. Therefore, we decided that the Plan does not have to pre-approve neupogen (J1442).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for the outpatient services (99214) provided on November 4, 2020.
You asked the Plan to pay this claim. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says the claim was not submitted with a correct Place of Service code. Maximus overturned the Plans denial because insufficient claim information had been submitted with the case file. The Plan requested a reopen and submitted the required claim information.
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, this claim cannot be paid as billed due to the omission of an appropriate Place of Service code. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for the outpatient services (99214) provided on November 4, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for two (2) psychotherapy office visits (90853) provided on January 12, 2021, to January 14, 2021. You asked the Plan to pay for the psychotherapy office visits. You say that services provided are a covered service. The Plan denied your request. The Plan says that services were provided by an out-of-network provider without prior authorization.
The Plan must follow Medicare rules. Medicare rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. The Plan rules say that they will cover services from either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. The Plan contract also says that a referral or prior authorization is not required to receive services from out-of-network providers.
We looked at the file and rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy office visits have been met. Specifically, the contract with the Plan states that a referral or prior authorization is not required for services rendered by an out-of-network provider. Therefore, we decided that the Plan has to pay for two (2) psychotherapy office visits (90853) provided on January 12, 2021, to January 14, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on January 26,
2021, by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the services rendered were
medically necessary. The Plan denied your request. The Plan says the service was rendered by a nonparticipating
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 had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on
January 26, 2021, by an OON provider.