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

We decided that the Plan does not have to pre-approve Blueprint and MammaPrint genetic testing for the
enrollee.
You asked the Plan to pre-approve Blueprint and MammaPrint genetic testing. You say that this claim should
be paid. The Plan denied your request. The Plan says Medicare coverage criteria were 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 Agendia Breast
Cancer Test Suite, which includes the Blueprint and MammaPrint genetic testing assays. The Maximus
Physician Reviewer determined that the requested testing was medically reasonable and necessary in this case.
The Plan requested a reopen and argues that the Maximus reviewer did not address that this was a request for
two distinct genetic tests, the Blueprint and the MammaPrint, and the reviewer did not consider current
Medicare guidance regarding both tests. Our Medical Director has concluded that the Plan is correct in this
case. The enrollee is a 74-year-old woman who underwent simple mastectomies of the right breast (invasive
ductal carcinoma) and left breast (ductal carcinoma in situ).
The tumor size in the right breast was 9.0 cm in the greatest dimension. Invasive carcinoma was detected in the
right axillary lymph nodes. The Agendia Breast Cancer Test Suite, which includes MammaPrint and Blueprint,
was ordered. The Medicare LCA A55115, the Blueprint assay is a statutorily excluded test. In addition, per
LCD L35160, MammaPrint was not prospectively validated for breast cancer measuring 9 cm. Medicare
coverage criteria 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 Blueprint and MammaPrint genetic testing have not been met. Therefore, we
decided that the Plan does not have to pre-approve Blueprint and MammaPrint genetic testing for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pembrolizumab (J9271).

You asked the Plan to pre-approve Pembrolizumab. You say that Pembrolizumab is medically necessary and reasonable for the enrollee's medical condition. The Plan denied your request. The Plan says the FDA has no listed indication for the use of Pembrolizumab for the enrollee's tumor.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Pembrolizumab. Our reviewer says that Pembrolizumab is not medically reasonable and necessary for the enrollee. Our physician reviewer found the request is for Pembrolizumab as it has been shown to have some efficacy against tumors with this genetic mutation. The FDA has no listed indication for Pembrolizumab for the enrollee's tumor. Our reviewer found that the requested use of Pembrolizumab is not FDA-approved for the enrollee's diagnosis. Our physician reviewer also found that Pembrolizumab is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS) approved medical journal. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Pembrolizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Pembrolizumab (J9271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a comprehensive periodontal evaluation (D0180), intraoral complete series of radiographic images (D0210), 2D oral/facial photographic images obtained intraorally or extraorally (D0350), an unspecified diagnostic procedure (D0999), oral hygiene instructions (D1330), full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355), drugs or medicaments, dispensed in the office for home use (D9630), an unspecified adjunctive procedure (D9999 x3), and gingival irrigation (D4921 x4) provided on February 18, 2021.

You asked the Plan to pay for a comprehensive oral evaluation, a comprehensive periodontal evaluation, intraoral complete series of radiographic images, 2D oral/facial photographic images obtained intraorally or extraorally, an unspecified diagnostic procedure, oral hygiene instructions, full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit, drugs or medicaments, dispensed in the office for home use, an unspecified adjunctive procedure, and gingival irrigation. You say that you thought you had dental coverage. The Plan denied your request. The Plan says the services at issue are not covered benefits. You were not enrolled in the optional supplemental dental coverage on the date of service.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a comprehensive periodontal evaluation (D0180), intraoral complete series of radiographic images (D0210), 2D oral/facial photographic images obtained intraorally or extraorally (D0350), an unspecified diagnostic procedure (D0999), oral hygiene instructions (D1330), full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355), drugs or medicaments, dispensed in the office for home use (D9630), an unspecified adjunctive procedure (D9999 x3), and gingival irrigation (D4921 x4) provided on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the comprehensive oral evaluation (D0150), prophylaxis (D1110), the panoramic x-ray (D0330), the topical application of fluoride varnish (D1206), and the fillings (D2394 x 2) provided on May 5, 2021.
You asked the Plan to reimburse you for the dental services. You say that you called the plan and was given names of dental providers you could go to. You also say that you selected one and then you found out that the provider was opted out of Medicare, and you will not be reimbursed. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made for dental services performed by providers that have opted out of Medicare.
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 and the services are listed as covered, payment cannot be made for dental services performed by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to reimburse you for the comprehensive oral evaluation (D0150), prophylaxis (D1110), the panoramic x-ray (D0330), the topical application of fluoride varnish (D1206), and the fillings (D2394 x 2) provided on May 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospitalization.
You asked the Plan to pay for acute inpatient hospital care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the planned procedures are not listed on the CMS Inpatient Only List.
The procedure is currently approved as an ambulatory procedure and there is no documentation provided to support the expectation the enrollee will require a greater than two midnight stay. The record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 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. Specifically, medically necessary services can be obtained in an observational setting. This means admission into an acute inpatient hospital is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospitalization.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a mouth guard/stabilization device for TMJ.
You asked the Plan to pre-approve a mouth guard/stabilization device. You say that you feel that you need this device to stop the constant headaches associated with TMJ. The Plan denied your request. The Plan says that the requested dental services are not covered under Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and necessary. 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 mouth guard/stabilization device. Our reviewer says that the requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer found a review of the enrollee's medical record indicates that the pain associated with the TMJ was diagnosed as degenerative joint disease. Radiographs indicated abnormalities in the joint (osteorarthritis and other joint deformation). Placement of a dental appliance is reasonable and necessary and does not include the treatment of the teeth or structures supporting the teeth but is treating a medical condition. 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 mouth guard/stabilization device have been met. Therefore, we decided that the Plan has to pre-approve a mouth guard/stabilization device for TMJ.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of a Coflex device.

You asked the Plan to pre-approve Coflex. You say that this procedure is supported by studies and is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Coflex is experimental/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 Coflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Coflex device remains experimental. More research is needed to show the safety and efficacy of this device. High failure rates have been reported with similar devices. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Coflex have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical placement of a Coflex device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 28, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.
We looked at the file and Medicare rules. In this case, it is inappropriate to billed the testing with multiple CPT codes. Per Medicare rules, the lab services should be billed with one unit of service for one procedure code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ice machine (E1399).
You asked the Plan to pre-approve an ice machine. You say that you need help with the pain you are in. It's an ice machine. Your doctor diagnosed you with a torn rotator cuff. The Plan denied your request. The Plan says this item is not a 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 an ice machine (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the out-of-network (OON) provider on October 30, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the out-of-network (OON) provider on October 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the lumbar spine you had on April 26, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you have back pain and your doctor ordered this test to make sure you were healing ok. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($104.44) is less than your copayment obligation, you are responsible for the full allowed 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 $225 copayment for CT scans.
You have been asked to pay a $225 copayment for the CT scan. 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 computed tomography (CT) scan of the lumbar spine you had on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four dental cleanings per year.

You asked the Plan to pre-approve the additional cleanings. You say that the enrollee is at high risk for endocarditis. The Plan denied your request. The Plan says the plan covers two cleanings per year, and there are no unique circumstances that would allow for more than the allowed benefit of routine cleanings.

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 additional cleanings 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 additional cleanings. Our reviewer says that the request for additional cleanings per year is not medically reasonable or necessary. Our physician reviewer found a review of the literature did not reveal that a recommendation for more frequent dental cleanings for patients with cardiac conditions. There may be unique circumstances where a patient is not physically able to perform oral hygiene measures and more frequent cleanings may be necessary to reduce the inflammatory process of the gingivae. There is no indication that you are unable to carry out the proper oral hygiene procedures (frequent brushing, flossing and oral rinses) to maintain a degree of oral hygiene which would not require more than the standard two cleanings per year which would be the criteria for coverage.

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 additional cleanings have not been met. Therefore, we decided that the Plan does not have to pre-approve four dental cleanings per year.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the specialist visit and the incobotulinumtoxin injection you received on February 15, 2021 with a pain management doctor.
You asked the Plan to waive the cost sharing for the specialist visit and injection. You say that on your former plan, you only had to pay a $15 copayment for each service. You are asking why you have to pay more for this injection now. The Plan denied your request. The Plan says you were charged this cost sharing 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 $45 copayment for services with a specialist and 20% coinsurance for Medicare Part B-covered drugs. You have been asked to pay a $45 copayment for the specialist visit and 20% coinsurance for the injection.
Because a pain management doctor is considered a specialist, the specialist visit copayment applies. In addition, the incobotulinumtoxin injection you received is considered a Medicare Part B-covered drug. Because the allowed amount for this drug is $1928.50, and you are responsible for 20% coinsurance for drugs, your coinsurance for this drug is $385.70 ($1928.50 x 20% = $385.70) 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 cost sharing for the specialist visit and the incobotulinumtoxin injection you received on February 15, 2021 with a pain management doctor.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has make additional payment for the crown. We decided that the Plan does not have to make payment in full for the crown.
You asked the Plan to pay for the crown. You say that you paid this bill in full while the Plan paid nothing. The Plan says that the charge exceeds the allowable amount for this procedure.
We decided that the Plan has to make additional payment for the crown.
The Plan must follow Medicare rules. The rules state that 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 record shows that you received the crown and $605.40 was paid by the primary payer. The Plan is contractually obligated to make payment for covered services up to the maximum allowable charge (MAC). Any payments made by another entity cannot be considered to meet this obligation. After primary payment, you owe $849.60, which exceeds the Plan's MAC for this service. As such, the Plan must pay the $518 toward the remaining cost of this service. Therefore, we decided that the Plan has to make additional payment for the crown.
We also decided that the Plan does not have to make payment in full for the crown.
The Plan must follow Medicare rules. The rules state that 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 is only responsible for paying up to the MAC of $518. The contract says that for services obtained OON the Plan only pays up to a certain amount. If you choose to see an OON dentist, you might be billed for any amount greater than what the Plan pays. You are responsible for the difference between the billed amount and the combined amount paid by the Plan ($518) and the primary payer (605.40). Therefore, we decided that the Plan does not have to make payment in full for the crown.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 14, 2021.
You asked the Plan to pay for a limited oral evaluation. You say that you were referred to an oral surgeon and this service was necessary for treatment. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every Plan year
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 a limited oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on March 11, 2021. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 14, 2021.