Persius/hicric huggingface dataset:
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee required stand-by assistance to stand up and walk 10 feet times two. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower level of care. 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 waive the copayment for an X-ray provided on October 8, 2020.

You asked the Plan to waive the copayment for an X-ray. You say that you were not aware that the facility was outpatient and disagree with the charges. 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 $100 copayment for X-rays provided at an outpatient hospital facility. 

You have been asked to pay the allowed amount of $76, which is less than the $100 copayment for X-rays provided at an outpatient hospital facility. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an X-ray provided on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services you received from May 15, 2020, to July 1, 2020.

You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says out-of-network services are not covered.

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 services are not covered when provided by an out-of-network provider. The Plan contract clearly states that you must pay 100% of the cost for dental services received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the dental services you received from May 15, 2020, to July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician office visit services provided on August 5, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician office visit services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not provided. The Plan says that the member's primary care physician did not refer these services. The Plan says that these services could have been provided in-network.

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 physician office visit services provided on August 5, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 6, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says in most
cases care you receive from an out of network provider will not be covered. If you need medical care that
Medicare requires our plan to cover and the providers in our network cannot provide this care, you may get this
care from an out of network provider. You, or your PCP must obtain authorization from the Plan prior to
seeking care.

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
laboratory 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 laboratory services provided on July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on September 2, 2020, to September 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physical therapy. You say that a referral was obtained for these services. The Plan denied your request. The Plan says the rendering provider is out-of-network.
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. The referral that was provided lists a different provider than the provider who rendered these services. Therefore, we decided that the Plan does not have to pay for physical therapy provided on September 2, 2020, to September 15, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on September 19, 2020.

You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. 

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on September 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on October 15, 2020.

You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you contacted the Plan, but they were unable to find you an in-network provider. You also say that this provider advised that they accepted your insurance. The Plan denied your request. The Plan says the frequency limitation had been exhausted.

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, intraoral x-rays are limited to one procedure per plan year. The record shows that you received two intraoral periapical x-rays on October 15, 2020, one of which was covered by the Plan, and your intraoral x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on October 26, 2020.

You asked the Plan to pay for the intraoral periapical radiological images and limited oral evaluation. You say that you needed a second opinion. The Plan denied your request. The Plan says the limited oral evaluation is a non-covered service and you had the allowed intraoral periapical radiographic image already this 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation is not among those covered under this benefit. You exhausted your image benefit on October 14, 2020. Therefore, we decided that the Plan does not have to pay for the dental services provided on October 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on September 20, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges. 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 $220 copayment for ambulance services. 

You have been asked to pay a $220 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on September 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial ostectomy/sequestrectomy (D7550) provided on August 19, 2020.

You asked the Plan to pay for the partial ostectomy/sequestrectomy. You say that you were referred to this treating provider, and were not aware that they are out-of-network. The Plan denied your request. The Plan says this service is not covered under the Plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial ostectomy/sequestrectomy (D7550) provided on August 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the allograft, structural, for spine surgery only services coded 20931 and the autograft for spine surgery only add-on services coded 20936 provided on September 17, 2021.

You asked the Plan to pay for the allograft, structural, for spine surgery only services and the autograft for spine surgery only add-on services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services billed are not payable.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 20931. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the allograft, structural, for spine surgery only services and the autograft for spine surgery only add-on services have not been met.

Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that the autograft for spine surgery only add-on services coded 20936 have a status code of "B" which means this code is a bundled code. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the allograft, structural, for spine surgery only services coded 20931 and the autograft for spine surgery only add-on services coded 20936 provided on September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for dental services (D6065, D6057) received on September 21, 2020.

You asked the Plan to pay for the services. You say that all of the documents you received shows that crowns
are covered. The Plan denied your request. The Plan says that this is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers crowns once
per tooth per five years.

The Evidence of Coverage provided to MAXIMUS for review shows that crowns are a covered dental benefit.
Based on this information, we decided that the Plan's rules for coverage of the services have been met.
Therefore, we decided that the Plan has to pay for dental services (D6065, D6057) received on September 21,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a spinal orthosis (L0650) provided to the enrollee on
September 4, 2020.

You asked the Plan to pay for the services. You say that the denied charges should be reconsidered. The Plan
denied your request. The Plan says there was no claim from the ordering physician.

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 pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the available documentation in the case file does not support that the requested lumbar-sacral orthosis
was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria
established by the LCD. An appropriate history and a physical examination of the back would reasonably be
required to adequately assess whether the coverage criteria for a brace have been met. The documentation does
not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this
case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the
back.

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 pay for a spinal orthosis (L0650) provided to the enrollee on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on August 28, 2020.

You asked the Plan to waive the copayment for a specialist office visit. You say that you were not in his office or under his care. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for physician/practitioner services/in-network/specialist services. 

You have been asked to pay a $50 copayment for a specialist office visit. The correct copayment has been applied to the services that were provided. A specialist office visit falls within the physician/practitioner services/in-network/specialist services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on August 28, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on October 28,
2020.

You asked the Plan to waive the copayment for emergency care. You say that you had an allergic reaction to
dye after telling the staff you were allergic to it and feel that for this reason you should not be responsible for
the charges. 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 $90
copayment for emergency care.

You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency
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 copayment for emergency care provided on
October 28, 2020.

Your quality-of-care concerns have been handled separately by the health plan. Medicare does not permit
MAXIMUS to make a decision on this type of complaint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 4) and the gingival irrigation (D4921 x 4) provided from October 15, 2020, to October 19, 2020.

You asked the Plan to pay for the gingival irrigation. You say that the provider did not submit for pre-authorization as they were supposed to. The Plan denied your request. The Plan says gingival irrigation is not a covered 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, the requested items or services are not among those covered under this benefit. The Evidence of Coverage clearly states that gingival irrigation is not a covered service. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 4) and the gingival irrigation (D4921 x 4) provided from October 15, 2020, to October 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate services.

You asked the Plan to pre-approve bone marrow aspirate services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 bone marrow aspirate services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental in cases of spinal fusion. More research is needed to show safety and efficacy. Iliac crest bone graft is the gold standard for fusion. Therefore, you do not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspirate services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate services.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for AlloSure testing.

You asked the Plan to pay for AlloSure testing. You say that you would like reconsideration because this testing is a safe and effective method to aid in evaluating the probability of organ rejection. The Plan denied your request. The Plan says that this service does not meet the Plan's medical technology assessment criteria or medical policy guidelines.

The Plan follows Medicare rules. Medicare rules say that AlloSure assay is covered when specific clinical conditions are met. 

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 AlloSure testing. Our reviewer says that this testing is medically reasonable and necessary.

Our physician reviewer found Allosure is an accepted test to predict renal transplant rejection. This test, if negative, will prevent the need to perform renal biopsy to investigate and diagnose rejection. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of AlloSure testing have been met. Therefore, we decided that the Plan has to pay for AlloSure testing.