Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided on January 6, 2021, to February 3, 2021 by an out of network (OON) provider.
You asked the Plan to pay for outpatient mental health services. You say that you had to borrow money from your family members. You say that you would like to be able to pay them back. The Plan denied your request. The Plan says prior authorization was not obtained 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 for outpatient mental health services provided on January 6, 2021, to February 3, 2021 by an out of network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prostheses with computerized knees and advanced feet.
You asked the Plan to pre-approve a prostheses with computerized knees and advanced feet.. You say that this prosthetic equipment is medically necessary for your condition. The Plan denied your request. The Plan says the requested items exceed the member's needs.
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 prostheses with computerized knees and advanced feet. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the prostheses with computerized knees and advanced feet exceed the patient's function need and are not medically necessary. The physician documentation does not support that the patient will be a K3 ambulator given the multiple medical comorbidities and the patient's functional status of using a wheelchair. 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 prostheses with computerized knees and advanced feet. have not been met. Therefore, we decided that the Plan does not have to pre-approve a prostheses with computerized knees and advanced feet.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for services provided on January 31, 2020.
You asked the Plan to reduce the copayments for needle electromyography (95886), transcranial doppler (93890,93892), duplex scan (93882), transcranial doppler (93886), evaluation of extremity muscles (95886) and office visit (99204). You say that you don't believe you should be charged the same copay as a CT or MRI. The Plan denied your request. The Plan says you were charged the cost share 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 $50 copayment for the specialist office visit, and a $110 copayment for each outpatient diagnostic test.
You have been asked to pay a $50 copayment for the specialist office visit, a $25 copayment for a non-radiological test and a $110 copayment for each diagnostic tests. The needle electromyography (95886), transcranial doppler (93890,93892), duplex scan (93882), transcranial doppler (93886) and office visit (99204). needle electromyography (95886), transcranial doppler (93890,93892), duplex scan (93882), transcranial doppler (93886) and evaluation of extremity muscles (95886) fall within the Outpatient Diagnostic test benefit category. The office visit falls within the Physician Specialist Service. 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 reduce the copayments for services provided on January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).

You asked the Plan to pre-approve a total electric hospital bed. You say that this request is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extractions (D7210 x2) provided from March 31, 2021, through April 1, 2021.

You asked the Plan to pay for extractions. You say that the service was necessary, and you could not get in with an in-network provider. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of extractions have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these 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 extractions (D7210 x2) provided from March 31, 2021, through April 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve abobotulinumtoxina.
You asked the Plan to pre-approve the requested drug. You say that it will assist the enrollee to achieve maximum functional capacity. The Plan denied your request. The Plan says medical studies have not proven the drug is helpful for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 the requested drug. Our physician reviewer found that in this case, the enrollee has a large mouth ventral hernia without obstructive symptoms. The Medicare approved compendia do not contain supportive citations form the use of the requested drug for the enrollee's condition. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.
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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve abobotulinumtoxina
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure system.

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 heart failure and is receiving palliative milrinone. The record states that the enrollee does not have shortness of breath or worsening dyspnea on exertion. The record does not credibly indicate a baseline NYHA classification of III heart failure. The services are therefore not reasonable or 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 a CardioMEMs Heart Failure system.

Local Coverage Determination (LCD) L36419 referenced by the Plan is retired and not binding for the services at issue and was not used in the Maximus determination.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 16, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests 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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab
services provided on July 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (G0299) provided November 27,
2020.
You asked the Plan to pay for the home infusion services. You say that the services were medically necessary.
The Plan denied your request. The Plan says a corrected claim is required.
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 G0299 is not supported in the medical record. Specifically, the claim was not filed on
the UB-04 form and did not include the required elements for a home health claim. Based on this information,
we decided that Medicare rules for coverage of the home infusion services have not been met. Therefore, we
decided that the Plan does not have to pay for home infusion services (G0299) provided November 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a labial veneer (D2962) provided on March 4, 2021.
You asked the Plan to pay for a labial veneer. You say that the service should be covered. The Plan denied your request. The Plan says the service at issue 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 pay for a labial veneer (D2962) provided on March 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for medical supplies provided on February 22, 2021 by an out of network (OON) provider.
You asked the Plan to pay for medical supplies. You say that you did not know this provider was out-of-network. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available for these supplies.
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 medical supplies provided on February 22, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 2, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from March 20, 2021, through March 22, 2021.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were there for less than 48 hours, but it was coded for inpatient instead of observation. You say that you should only have to pay $90. The Plan denied your request. The Plan says the copayment 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 $220 copayment per day per admission for days 1-5 at an in-network inpatient hospital.
You have been asked to pay a $440 copayment for the inpatient stay. ($220/day x 2 days = $440). The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show this was an inpatient admission. 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 inpatient stay provided from March 20, 2021, through March 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 there are no services at the LTACH that you require that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary. Transfer to a lower level of care may be considered when treatment has completed.

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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custodial care services.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says custodial care is not covered.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. We find that the services at issue in this case are considered custodial in nature. Custodial care is not a covered benefit. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve custodial care services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on July 26, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 30903 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 30903 is control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method. We find that CPT code 30903 is not supported in the medical record. Specifically, the records do not support a complex control of nasal hemorrhage. There is a more appropriate code for the documented services. 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 pay for the surgical services rendered on July 26, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Qutenza 8% kit (1 Patch).
You asked the Plan to pre-approve the Qutenza patch. You say that this is medically necessary based on the
enrollee's medical history. The Plan denied your request. The Plan says that the drug is not being prescribed for
a medically accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
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 the Qutenza patch. Our reviewer says
that the requested Qutenza patch is medically necessary. Our physician reviewer found based on the medical
records provided and the Medicare-approved major drug compendia there is documentation that Qutenza is
Food and Drug Administration (FDA)-approved for the enrollee's diagnosis. The reviewer also found that there
is documentation that Qutenza is safe and effective and otherwise reasonable and necessary for this enrollee's
diagnosis.
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 Qutenza patch have been met. Therefore, we decided that the Plan has to
pre-approve Qutenza 8% kit (1 Patch).
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 22, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says tests not ordered by the physician who is treating the enrollee are not reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met.
Therefore, we decided that the Plan does not have to pay for the lab services provided on July 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyewear provided on November 12, 2020.
You asked the Plan to reimburse you for the eyewear. You say that you paid for the vision items and for an extra pair of eyeglasses. You say that the vendor charged you and, also billed the Plan and was paid twice. The Plan denied your request. The Plan says the vendor charged you for the upgrades on the lenses, which are not covered under your Plan along with the cost share as per the benefit plan. Also, you paid for the second pair of eyeglasses, which are not covered under you Plan.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan paid the vendor the correct benefit
allowance for one pair of standard eyeglasses. Therefore, we decided that the Plan does not have to reimburse
you for eyewear provided on November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341 x 2), a complete upper denture (D5110), and a partial lower denture (D5214).
You asked the Plan to pre-approve the dental services. You say that you were advised that this was for a deep cleaning which is still a covered service under periodontal maintenance. The Plan denied your request. The Plan says periodontal scaling and root planing is not listed as a covered service. The Plan also says that dentures are not listed as covered services either.
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 dentures and periodontal scaling and root planing are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341 x 2), a complete upper denture (D5110), and a partial lower denture (D5214).