Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per quadrant (D4341).
You asked the Plan to pay for periodontal scaling and root planing - four or more teeth per quadrant (D4341). You say that the requested service was necessary due to a tooth splitting. The Plan denied your request. The Plan says the requested service is not covered under your supplemental 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 periodontal scaling and root planing - four or more teeth per quadrant (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant supported crown (D6066).
You asked the Plan to pre-approve an implant supported crown. You say that this service should be covered as it is medically necessary, and your contract does not state that crowns cannot be used on implanted teeth. The Plan denied your request. The Plan says crowns cannot be covered for use in implanted teeth. The Plan offers coverage of crowns, but all covered crowns require prior review and are subject to limitations and exclusions. Crowns are not covered for implanted teeth. Only codes D2740, D2750 and D2752 are covered, which only apply to natural teeth.
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 an implant supported crown (D6066).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve backup battery for CPAP machine.
You asked the Plan to pre-approve backup battery. You say that this is necessary for power outages. The Plan denied your request. The Plan says this is not covered item.
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 backup battery for CPAP machine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee does not have a ventilator, spasticity, or use of intermittent catheterization. The enrollee does not have a high risk of skin breakdown. The power tilt and recline is therefore not medically necessary. There is no evidence of severe lower extremity swelling or a case or knee brace that requires elevating leg rests. The group 2 power wheelchair and accessories exceed the enrollee's medical need and is therefore 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) and a suspension sleeve (L2397) provided on August 21, 2020.
You asked the Plan to pay for a knee orthosis and a suspension sleeve. You say that the requested items are medically necessary for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that a supplier of a covered item of DME may not contact an individual by telephone regarding the furnishing of a covered item to the individual, except in certain scenarios outlined the Medicare rules section. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee orthosis and a suspension sleeve have not been met. Specifically, the Plan has attested that this enrollee was contacted via an unsolicited phone call regarding provision of the items at issue. As such, no payment may be made for these items. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833) and a suspension sleeve (L2397) provided on August 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee brace (CPT Code L1851) for the enrollee.
You asked the Plan to pre-approve a knee brace (CPT Code L1851). You say that this knee brace is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a knee orthosis. The Maximus Physician Reviewer determined the enrollee may benefit from the use of the requested brace. The Plan argues the reviewer did not apply the LCD.
The Plan is correct. In this case, the Maximus physician reviewer did not reference the LCD coverage criteria for a knee orthosis. Additional information was submitted, stating that there was instability in the examination of the enrollee's knee. However, this statement regarding knee instability is not substantiated by clinical documentation in the case file. After review of the additional information, our Medical Director has concluded the medical records provided do no support that the coverage criteria for a knee orthosis, as established by LCD L33318, were met in this case. 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 knee brace have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee brace (CPT Code L1851) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mandibular partial denture (D5214).
You asked the Plan to pre-approve the mandibular partial denture. The Plan denied your request. The Plan says this service is only covered if there are less than 8 posterior teeth in occlusion.
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 mandibular partial denture 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 mandibular partial denture. Our reviewer says that the criteria for coverage for a mandibular removable partial denture (D5214) have not been met. Our physician reviewer found the enrollee's dental record and radiograph indicate that there are eight posterior teeth in functional occlusion on the right side and six posterior teeth in functional occlusion on the left side. Our reviewer also found that a mandibular removable partial denture would not appreciably increase the enrollee's masticatory function. 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 mandibular partial denture have not been met. Therefore, we decided that the Plan does not have to pre-approve the mandibular partial denture (D5214).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on November 30, 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 November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88104, 88305, 88312) provided on August 28, 2020.
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with a necessary modifier.
The Plan must follow Medicare rules. Medicare rules say that only the hospital may bill for the technical component (TC) of a physician pathology service provided to an inpatient or outpatient. We looked at the file and Medicare rules. The records show that the services at issue were provided to a hospital outpatient but were not billed with modifier 26 to indicate that only the professional component and not the technical component is being billed. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (88104, 88305, 88312) provided on August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the biopsy of soft tissue for upper left and upper right quadrants (D7286).
You asked the Plan to pre-approve the biopsy. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 the biopsy of soft tissue for upper left and upper right quadrants (D7286).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the periodontal maintenance (D4910).
You asked the Plan to pay an additional amount for the periodontal maintenance. You say that the Plan previously covered the full amount billed by the provider. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 payment is in excess of those covered under this benefit. In this case, the Plan paid 100% of the Maximum Allowable Charge (MAC) for the requested service. You are responsible for any amount over the Plan's MAC. Therefore, we decided that the Plan does not have to pay an additional amount for the periodontal maintenance (D4910).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a periodontal scaling and root planing of four or more teeth per quadrant (D4341) of the lower right quadrant.
You asked the Plan to pre-approve the scaling and planing. The Plan denied your request. The Plan says the documentation provided shows that the enrollee has less than four teeth present in the quadrant where the scaling and root planing have been requested.
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 scaling and planing 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 scaling and planing. Our reviewer says that a periodontal scaling and root planing of four or more teeth per quadrant (D4341) for the lower right quadrant is not medically necessary. Our physician reviewer found in the lower right quadrant there are three remaining teeth, #'s 27, 30, and 31. There is an existing long span bridge from tooth #'s 20 to 31 with abutments on tooth #'s 20, 21, 22, 27, 30, and 31. Our reviewer found that there are six abutments on the the lower bridge with three on the lower right quadrant. The service code D4341 is not medically necessary as this code is reserved for situations where there are four or more teeth remaining in a quadrant that are affected by periodontal disease. Our physician reviewer also found that a lesser code exists for situations where there are three or less teeth remaining in a quadrant and require scaling and root planing. 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 scaling and planing have not been met. Therefore, we decided that the Plan does not have to pre-approve a periodontal scaling and root planing of four or more teeth per quadrant (D4341) of the lower right quadrant.
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 care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial due to a lack of records submitted to substantiate their decision. The Plan requested a reopen and provided records.
Our Medical Director looked at the case file and the reopen request as well as the additional records provided. At issue is IRF coverage. The Maximus Physician Reviewer determined that Plan did not provide suitable records for review. As such, the health plan has failed to support their denial. The Plan requested a reopen and submitted the required medical records. Based on the documentation provided, the records do not support that the complexity of your nursing, medical and rehabilitation needs require an acute inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that your condition requires at least 3 hours a day/5 day a week, or 15 hours over 7 consecutive days, of therapy services. Medicare coverage criteria for IRF admission 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested MRI.
You asked the Plan to pre-approve an MRI. You say that the requested MRI is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an MRI of the lumbar spine. The Maximus Physician Reviewer determined that radicular pain (pain with radiation) was the indication for study. The Plan argues that there was no documentation of red flag symptoms, failure of previous treatment, or history of prior back surgery or trauma. The medical records show that you were evaluated via telehealth for a complaint of 2 weeks of lower back and right leg pain. You stated the pain radiated into the right calf, and that you had weakness when standing or walking. A diagnosis of right lower extremity radiculopathy was made, and an MRI was ordered.
Our Medical Director has concluded that the Plan is correct in this case. The documentation is insufficient to demonstrate that an MRI of the lumbar spine was medically reasonable and necessary at that time. The severity of pain, and response to conservative treatment is not documented, nor is there documentation of the severity of weakness and/or numbness. Medicare coverage criteria for an MRI 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 an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI), spinal canal and contents, lumbar; without contrast material (CPT Code 72148).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport provided to the enrollee on August 24, 2020.
You asked the Plan to pay for this transport. You say that this transport was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen report. At issue is coverage for ambulance transport. The Maximus Physician Reviewer determined that pain is a subjective complaint and can be a symptom of severe acute illnesses. The Plan argues that the enrollee could have been safely transported by another type of motor vehicle. The Plan is correct in this case. The documentation does not support that the another means of transport was contraindicated for the enrollee at the time of transport. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on the date of transport. The documentation does not support that the ambulance transport was medically reasonable and necessary for the enrollee in this case. Medicare coverage criteria for transport of this type 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 this transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transport provided to the enrollee on August 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95939-TC, 95927-TC, 95938-TC,95861-TC, 95868-TC) provided on October 1, 2020.
You asked the Plan to pay for neuromonitoring services. You say that these services should be covered. The Plan denied your request. The Plan says payment for these services is bundled into the hospital facility payment.
The Plan must follow Medicare rules. Medicare rules say that payment may not be made for the technical component (TC) of radiology services furnished to hospital patients. We looked at the file and Medicare rules. The record shows that the services at issue were provided to an enrollee in an inpatient hospital stay. The billed technical component (TC) cannot be paid in this case. Based on this information, we decided that Medicare rules for coverage of neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95939-TC, 95927-TC, 95938-TC,95861-TC, 95868-TC) provided on October 1, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on December 22, 2020.
You asked the Plan to pay for the office visit. You say that the provider is in-network with the Plan. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 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 office visit provided by an out-of-network provider on December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 4, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are 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 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 physician's services provided on December 4, 2020.