Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan does not have to provide coverage for inpatient admission for the enrollee.
You asked the Plan to provide coverage for acute inpatient hospital care for the enrollee. 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 coverage criteria.
Our Medical Director reviewed the case file and the reopen request. At issue is coverage for an inpatient
admission. The Maximus Physician Reviewer determined that it was reasonable to think that a wound infection
and/or cellulitis requiring hospitalization and intravenous antibiotics would require at least 2 midnights. The
Plan requested a reopen and states at the time of admission, the enrollee had no infection or cellulitis and was
not requiring intravenous antibiotics. Our Medical Director says the enrollee had previously undergone right
hamstring tendon repair surgery which was followed by infection. The enrollee required revision of the surgical
wound on the right, and she was treated with IV vancomycin. Surgery was planned for the left side. The Plan is
correct in this case. The enrollee did not have an active infection, and the documentation does not support that
it was reasonable for the admitting physician to expect that the enrollee's necessary hospital care would span
two midnights. Medicare coverage criteria for inpatient admission 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
acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to provide
coverage for inpatient admission for the enrollee.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to hold you harmless for the ambulance services (A0425 and A0428) provided on
September 28, 2020.
You asked the Plan to hold you harmless for the ambulance services. You say that you would like
reconsideration because the member was brought to a facility for a CT Scan then transferred back to the
original facility. The Plan denied your request. The Plan says that these services were rendered by an out-of-network
provider without authorization.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.
The enrollee was referred for the ambulance services by a contract provider. The file does not show that the
plan provided notice that the ambulance services would not be covered. Under Medicare rules, this means the
ambulance services is considered approved by the plan. Therefore, we decided that the Plan has to hold you
harmless for the ambulance services (A0425 and A0428) provided on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on September 15, 2020.
You asked the Plan to pay for the resin-based composite. You say that you were advised that the Plan would cover everything. You also say that you were not aware that the Plan only covered one resin filling or restoration per year. The Plan denied your request. The Plan says your dental benefit for resin-based composites had been exhausted. The Plan also says that you signed a treatment plan with the provider that shows there was no coverage under your dental benefit for this resin-based composite, and that you would be fully responsible for the charges for this service.
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, resin filling or restoration is limited to 1 procedure per year. The record shows that you received a resin-based composite on August 12, 2020, and your resin filling or restoration benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on September 15, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to provide coverage for a Positron Emission Tomography (PET) scan of the brain. You asked the Plan to provide coverage for a PET scan of the brain. You say that a PET scan is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. We overturned the Plans denial. The Plan requested a reopen and stated that we did not apply the correct coverage criteria. Our Medical Director looked at the case file and the reopen request. At issue is coverage for a PET scan of the brain. The Physician Reviewer determined that the physician letter described a "possibility of frontotemporal dementia". The Plan requested a reopen and stated that the NCD states specific medical record documentation and evaluation are required for Medicare coverage. Our Medical Director says the Plan is correct in this case. The available documentation in the case file does not support that the coverage criteria established by NCD 220.6.13 were met. The documentation is insufficient to demonstrate that the onset, clinical presentation, or course of cognitive impairment is such that the requested PET scan is reasonably expected to help clarify the diagnosis between FTD and AD and help guide future treatment. 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 a PET scan of the brain have not been met. Therefore, we decided the Plan does not have to provide coverage for a Positron Emission Tomography (PET) scan of the brain.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the technical component of portable x-ray services provided on September 10, 2020.
You asked the Plan to pay for the technical component of portable x-ray services. You say that the codes billed are eligible for payment. You say that the place of service billed is correct. You say that you are a mobile x-ray unit that provides x-rays to SNFs and other care homes. The Plan denied your request. The Plan says the technical component of diagnostic tests are subject too consolidated billing and must be billed by the SNF. The Plan says that an outside entity that actually furnishes the technical component would have to seek payment from the SNF and not the Plan.
The Plan must follow Medicare rules. Medicare rules say that when a SNF resident receives a portable x-ray service the technical component must be included on the SNF's bill for the resident's covered stay, rather than being billed separately. We looked at the file and Medicare rules. The records show that the portable x-ray services in dispute were supplied to the enrollee during a covered SNF stay. Based on this information, we decided that Medicare rules for coverage of the technical component of portable x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the technical component of portable x-ray services provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forspecialist services provided on September 24, 2020 by an out of network (OON) provider.You asked the Plan to pay forspecialist services. You say that you would like this claim paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available for these services.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 forspecialist services provided on September 24, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Jazzy ZeroTurn Mobility Scooter (K0899).You asked the Plan to pay forthe power scooter. You say that you would like reconsideration because you are having trouble getting around.The Plan denied your request. The Plan says the specific powermobility device being requested has been found not to meet the definition of a specificpower operated vehicle and/or a power wheelchair as defined by Medicare.The Plan must follow Medicare rules. Medicare rules say that a POV or PWC which has not beenreviewed by the Pricing, Data Analysis, and Coding (PDAC) contractor or which has been reviewed by the PDAC and found not to meet the definition of a specific POV/PWC will be denied as not reasonable and necessaryWe looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power scooter have not been met. The records indicate that you are requesting a scooter which has not been reviewed by the PDAC or found not to meet the definition of a specific POC/PWC.Therefore, we decided that the Plan does not have to pay forthe Jazzy ZeroTurn Mobility Scooter (K0899)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life Alert device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a Life Alert device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansayscare can be provided in the current inpatient hospital.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-approvethe 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 appears to be more stable but requires additional acute care services including weaning attempts to determine the patient's long-term needs which can be safely administered at the current acute care setting. The enrollee does not require services at the LTACH that are not already available and covered at the current setting. There are no services at the LTACH that are not already available and covered at the current setting. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered when weaning has been attempted.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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveInsertion of interlaminar/interspinous process stabilization/distraction device (22869) (vertiflex device).You asked the Plan to pre-approvea vertiflex device. You say that the device is medically necessary.The Plan denied your request. The Plan says the device is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental and there is not enough information to determine its safety and efficacy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of vertiflex device have not been met. Specifically, there is not information on the devices safety and efficacy making this device not reasonable or necessary for the enrollee's diagnosis.Therefore, we decided that the Plan does not have to pre-approveInsertion of interlaminar/interspinous process stabilization/distraction device (22869) (vertiflex device).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pay forvision refraction services received on September 4, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe enrollee would not be eligible for reimbursement of the refraction portion of theclaim.The Plan must follow Medicare rules. The rules say that Medicare does not cover refraction.The services you asked the Plan to pay for are considered refraction services.Therefore, we decided that the Plandoes not haveto pay forvision refraction services received on September 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVictoza Inj 18mg/3ml.You asked the Plan to pre-approveVictoza Inj 18mg/3ml. You say that the service is medically necessary.The Plan denied your request. The Plan says the service is not covered under the enrollee's benefit Plan.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveVictoza Inj 18mg/3ml
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for SNF stays provided from August 10, 2020, to October 8, 2020.
You asked the Plan to waive the copayments for SNF stays. You say that you disagree with the charges because you were told that the stay would be covered. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment for days 1-20 and a $160 copayment for days 21-100 for SNF care. You had a SNF stay from August 10, 2020, to August 31, 2020. You are not being charged a copayment for days 1-20 (August 10, 2020, to August 29, 2020). You are responsible to pay a copayment for days 21 (August 30, 2020). The total amount you owe for this stay is $160. You had a SNF stay from September 17, 2020, to October 8, 2020. This stay is within the same benefit period as the previous SNF stay. Therefore, you are responsible to pay a $160 copayment for days 22-42 (September 17, 2020, to October 7, 2020). The total amount you owe is: $160 (copayment) x 22 (SNF days) = $3,360. The total amount you owe for both stays is: $160 + $3,360 = $3,520. You have been asked to pay the total copayment amount of $3,520 for SNF stays. SNF stays fall within the SNF care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the copayments for SNF stays provided from August 10, 2020, to October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction received on September 15, 2020.
You asked the Plan to pay for the eye refraction. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
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 only covers specific vision services. We looked at the file and the Plan's rules. Review of the file shows that you received an eye refraction on September 15, 2020. Your contract with the plan specifically states that eye refractions are not covered. In addition, you signed a notice of non-covered services acknowledging that the refraction fee was not covered and would be your responsibility if not covered. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction received on September 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an esophageal motility study.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has colonic diverticulosis, a personal history of colon polyps, and a family history of colon cancer. The records do not support any indication for the esophageal motility study. There is no documentation of non-cardiac chest pain, dysphagia, esophageal motility problems associated with systemic disease, pre- or post-operative evaluation, or pH monitoring to assess the location of the lower esophageal sphincter for proper electrode positioning. The services are not medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an esophageal motility study.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 11, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says
the out-of-network provider would be responsible for securing a 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
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 subsequent nursing facility care provided on July 11, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the sleep study rendered on September 10,
2020.
You asked the Plan to waive the copayment for these services. You say that you should not have to pay the
copayment. The Plan denied your request. The Plan says the copayment was applied correctly.
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 $200
copayment for all other diagnostic and nuclear medicine radiological services.
Review of the file shows that you received a sleep study on September 10, 2020. Per the contract with the Plan,
there is a $200 copayment for all other diagnostic and nuclear medicine radiological services. This cost sharing
is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed
amount for these services was $130.90. Given that the allowed amount was less than the $200 copayment, you
have been asked to pay $130.90 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the sleep study rendered on
September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean autogenous connective tissue graft procedure represented by code D4273.You asked the Plan to pre-approvean autogenous connective tissue graft procedure. You say that the requested treatment is medically necessary because of 50% bone loss in between implants. You say that you have arthritis on 65% of your body, bone degenerate loss and trigeminal neuralgia.The Plan denied your request. The Plan says the code being requested is not listed as 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-approvean autogenous connective tissue graft procedure represented by code D4273