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

We decided that the Plan does not have to waive the copayment for an x-ray (73503) provided June 25, 2020.
You asked the Plan to waive the copayment for the x-ray. You say that you never had to pay for this service in the past. The Plan denied your request. The Plan says the correct copayment was 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 X-rays. You have been asked to pay a $35 copayment for the x-ray. The x-ray falls within the X-rays benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an x-ray (73503) provided June 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plandenied your request. The Plan says the stay is not medically necessary.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 patient appears to be more stable but requires additional short-term acute care services to further stabilize which can be safely completed at the current facility. The patient does not require services at the LTACH that are not already available and covered at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed and the patient is more stable.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-approveLTACH services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric services provided on December 19, 2019 by an out of network provider.
You asked the Plan to pay for the psychiatric services. You say that the facility did not obtain the authorization but the services were provided in good faith. The Plan denied your request. The Plan says you did not request prior authorization.
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 the psychiatric services provided on December 19, 2019 by an out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approveSNF services. You say that the enrollee needs to get his strength back.The Plan denied your request. The Plan says the enrollee has no medical or therapy needs.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNFwhen the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that from a nursing perspective, the enrollee had stable vital signs, his lungs were clear, and he received oral medications. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a standby assist level with functional mobility. He required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services ona daily basis. He does not meet severity of illness or intensity of service criteria for 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea genicular nerve block.You asked the Plan to pre-approvethe requested services. The Plan denied your request. The Plan says there is little medical evidence that shows this type of nerve block is helpful and safe.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 requested services. Our physician reviewer found that there is little medical evidence that shows the requested nerve block is safe and effective. The requested nerve block is not medically reasonable and necessary to treat yourcondition.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 requested services have not been met.Therefore, we decided that the Plan does not have to pre-approvea genicular nerve block.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection (J9035) provided March 27, 2020.
You asked the Plan to pay for the injection. You say that the service was medically necessary. The Plan denied your request. The Plan says the service was not billed with a valid CPT code.
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 code J9035 is not supported in the medical record. Specifically, Medicare rules require that Avastin injection for off label ophthalmic use be billed using CPT code J7999. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pay for an injection (J9035) provided March 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for dental services (D7140, D5140, D51110)
with an out-of-network provider.
You asked the Plan to pre-approve the services. You say that the provider is not out-of-network. The Plan
denied your request. The Plan says this is not a covered benefit.
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 pre-approve a
referral for dental services (D7140, D5140, D51110) with an out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on tooth #29.

You asked the Plan to pay for the resin-based composite. You say that your tooth was filled, and the filling came out a week later. You also say that you went back to have the tooth refilled, and you are being billed for the same tooth twice.The Plan denied your request. The Plan says fillings are limited to 1 per tooth surface per year. The Plan also says that you received a filling.

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, fillings are limited to 1 per tooth surface per year. The record shows that you received a resin-based composite on tooth #29, and your fillings benefit for tooth #29 had been exhausted.Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on tooth #29.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy on February 20, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that the copayment should be
dismissed because a well-trained doctor recommended you needed a colonoscopy because you are high-risk.
The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300
copayment for each Medicare-covered diagnostic colonoscopy.
You have been asked to pay a $300 copayment for the colonoscopy. The colonoscopy falls within the
"Diagnostic Colonoscopy" benefit category. The medical record shows that the colonoscopy was performed
due to a history of polyps.
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 colonoscopy provided on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the out of area outpatient office visit (99214) provided June 23, 2020.
You asked the Plan to pay for the office visit. You say that the records provided should support the necessity of
the service in dispute. The Plan denied your request. The Plan says enrollee's must receive their medical
services from an in-network provider with the exception being urgent or emergent services. Non-emergent
services with non-contracted providers require prior authorization before services being rendered.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the
out of area outpatient office visit (99214) provided June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 5, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
physician?s 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 physician's services provided on August 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on August 24, 2020.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 diagnostic radiology 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 diagnostic radiology services provided on August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for contact lens fitting. We decided that the Plan does not
have to waive the copayment for the eye exam and eye refraction services.
You asked the Plan to waive the copayment for contact lens fitting. You say that you would like this claim
reprocessed and approved for payment. The Plan says that the claim has processed correctly, and no additional
reimbursement is due.
We decided that the Plan has to reimburse you for the contact lens fitting.
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 with an allowance of $100 for services rendered.
We looked at the file and the Plan's rules. The file indicates that this was a contact lens fitting that would fall
under the $100 benefit. We did not see where this service would be denied for payment. Based on this
information, we decided that the Plan's rules for coverage of contact lens fitting have been met. Therefore, we
decided that the Plan has to reimburse you for the contact lens fitting.
We also decided that the Plan does not have to waive the copayment for the eye exam and eye refraction
services.
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 when received from an OON provider with a $75 allowance. Any
amount over $75 is your responsibility.
We looked at the file and the Plan's rules. The file indicates that the Plan has already reimbursed you $75 for
the eye exam and eye refraction services. The remaining amount is what you owe for services received from an
OON provider. Based on this information, we decided that the Plan's rules for coverage of the eye exam and
eye refraction services has processed correctly and no additional reimbursement is due. Therefore, we decided
that the Plan does not have to waive the copayment for the eye exam and eye refraction services.
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
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy, premolar tooth (excluding final restoration) (D3320).
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy, premolar tooth (excluding final restoration) (D3320).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus administratively overturned the case for a lack of medical records. The Plan requested a reopen and provided the required medical records.

Our Medical director looked at the case file and the medical records submitted. At issue is coverage for LTACH services. The enrollee has a past medical history of diabetes, hypertension, chronic kidney disease, and obesity. The enrollee was admitted to the acute care hospital on September 21, 2020 with acute respiratory failure due to Covid-19 pneumonia. The enrollee was intubated. A tracheostomy and PEG tube were placed on October 13, 2020. On October 18, 2020, the enrollee remained critically ill and remained in the ICU. 
Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee was receiving acute hospital care, and acute care services had not been denied. The documentation did not support that the enrollee in this case required services at the LTACH that were not available at the acute care hospital where he was receiving acute care. The documentation does not support that the requested LTACH services were medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at the time. 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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower limb prostheses.
You asked the Plan to pre-approve lower limb prostheses. You say that you are appealing with supporting documentation. The Plan denied your request. The Plan says the denial of authorization for these items is correct, because the clinical findings presented do not support that the enrollee is a K3 ambulator.
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 lower limb prostheses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the progress notes do not support that the enrollee is a K3 level ambulator. Per records the enrollee used a single point cane prior to amputation. The treating provider's notes do not indicate evidence of the enrollee's functional status at a K3 level; therefore, the requested K3 items exceed the enrollee's medical need. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lower limb prostheses have not been met. Therefore, we decided that the Plan does not have to pre-approve lower limb prostheses.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Vertiflex superion device.You asked the Plan to pre-approvethe device. You say that the services are necessary.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 device. Our reviewer says that the requested items/services are notconsidered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy. There is no instability. Hardware is not needed.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 device have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Vertiflex superion device
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinuation of inpatient mental health care from January 14, 2021, forward.You asked the Plan to pre-approveinpatient mental health care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.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 mental health care. Our physician reviewer found based upon review the records provided for the admission, you do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of January 14, 2021, forward asyou were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were cooperative/compliant with treatment while not showing any threats the safety.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 mental health care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinuation of inpatient mental health care from January 14, 2021, forward.