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

We decided that the Plan does not have to pay for the office visit provided by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that this care was medically necessary. The Plan denied your request. The Plan says they do not cover services provided out of network except in limited circumstances. The services in this case were not urgent or pre-approved.

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 the office visit provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.

You asked the Plan to pre-approve facet joint injections. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the clinical information does not describe positive facet joint examination results at the requested levels.

The Plan follows Medicare rules. Medicare rules state that facet joint injections are covered under certain clinical indications.

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 facet joint injections. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician reviewer found this request overlaps with prior surgical levels and there are no physical examination findings that delineate which levels are the suspected pain generators. Therefore, this is deemed not medically reasonable or 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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the brain.

You asked the Plan to pre-approve MRI. You say that the enrollee has epilepsy and risk of stopped medication. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee's seizures are neither newly onset nor drug resistant.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 MRI. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested MRI. Our physician reviewer found the enrollee is said to have been seizure free for 7 to 8 years. There would not readily be an indication for the performance of any form of advanced imaging at this time. This MRI of the brain would not be useful in guiding current or future treatment strategies, nor would it be of diagnostic utility either. In this context, the service cannot be determined to be medically reasonable and necessary at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the brain.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services and wound care provided by a participating provider on October 12, 2020, to October 19, 2020.
You asked the Plan to waive the copayment for specialist services and an outpatient surgery. You say that you cannot afford these copayments. You say that you feel like you should only owe $45 for each visit. The Plan denied your request. The Plan says the correct copayments have 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 $45 copayment for physician/practitioner services/in-network/specialist and a $225 copayment for outpatient surgery/in-network. You have been asked to pay a $45 copayment for specialist services and a $225 copayment for an outpatient surgery. The total amount you are being asked to pay is $495 ($45 + $225 + $225 = $495). Wound care is considered an outpatient surgery; therefore, the correct copayments have been applied. Specialist services fall within the physician/practitioner services/in-network/specialist benefit category and an outpatient surgery falls within the outpatient surgery/in-network 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 specialist services and wound care provided by a participating provider on October 12, 2020, to October 19, 2020.
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 admission is 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 in the Medicare rules section.

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 minimal assistance for bed mobility, to sit down, and to walk 30 feet. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for infrared light therapy (97026).

You asked the Plan to pay for infrared light therapy. You say that kindly process E&M per notes attached. The Plan denied your request. The Plan says infrared therapy is considered not reasonable and necessary by Medicare and is excluded from coverage.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of infrared light therapy have not been met. Therefore, we decided that the Plan does not have to pay for infrared light therapy (97026).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Botox injection for the enrollee.
You asked the Plan to pre-approve injection. You say that this is medically necessary. The Plan denied your request. The Plan says this request is not indicated for prostate pain.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Botox injection of pelvic floor is considered experimental or investigational for the treatment of prostatodynia and chronic pelvic pain syndrome. The quality of the evidence is low to very low in most cases, meaning that there is much uncertainty surrounding the results. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Botox injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).

You asked the Plan to pay for a pneumatic compression device. You say that the requested item is medically necessary. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care.

You asked the Plan to waive the copayment for the inpatient care. You say that you feel this copayment should be waived, because the enrollee was admitted to hospice care, and then passed away a day later. The Plan denied your request. The Plan says they have filed a separate grievance regarding your concerns, however the copayment amount for the inpatient care was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $395 copayment for each of the first 4 days of inpatient hospital care.

The enrollee has been asked to pay a $790 copayment for two days of inpatient care ($395 x 2 days = $790). This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous laser treatment.
You asked the Plan to pre-approve the endovenous laser treatment. You say that you would like reconsideration because the member is bothered by swelling and discomfort. The Plan denied your request. The Plan says there is no notation that the member has had an ultrasound of their leg anatomy or that there are no other issues such as blood clots or artery disease.
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 the endovenous laser treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for coverage requires that the patient have documented reflux in the veins to be treated and the absence of deep vein thrombosis. The documentation provided does not include a duplex ultrasound demonstrating these elements. Additionally, coverage criteria require an absence of significant peripheral artery disease. The member has a documented history of peripheral artery disease and has
numerous cardiovascular risk factors. The recent vascular provider evaluation does not include a pulse examination and does not include noninvasive assessment of arterial perfusion. 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 endovenous laser treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous laser treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a pulmonary embolism requiring thrombectomy. Her medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Additionally, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the primary closure of a sinus perforation (D7261) provided on October 28, 2020.
You asked the Plan to pay for the primary closure of a sinus perforation. You say that you were not advised of the cost of the surgery. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 primary closure of a sinus perforation (D7261) provided on October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on September 25, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that the physician was unprofessional and 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 $30 copayment for specialist visits. You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 visit provided on September 25, 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 reimburse you the allowance for the gym membership.

You asked the Plan to reimburse you the allowance for the gym membership. You say that you bought a 2-year membership and would now like the allowance for the year 2021. The Plan denied your request. The Plan says you were already reimbursed for that date of service.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits with a reimbursement of $240 and the date of services is the date you make a payment.

The Plan's rules for coverage of gym benefits have not been met because you already submitted a claim and received the allowance. Therefore, we decided that the Plan does not have to reimburse you the allowance for the gym membership.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three posterior resin-based composites.

You asked the Plan to pay for the posterior resin-based composites. You say that you were told that these fillings were covered at no cost to you. The Plan denied your request. The Plan says this service is 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 items or services are not among those covered under this benefit. The Plan only provides coverage for resin-based composites on anterior teeth. These resin-based composites were provided on posterior teeth. Therefore, we decided that the Plan does not have to pay for the three posterior resin-based composites.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for thyroid stimulating hormone testing (84443).

You asked the Plan to waive the copayment for thyroid stimulating hormone testing. You say that you should not be charged because you doctor forgot to request this on an earlier date of service. The Plan denied your request. The Plan says this processed 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 $10 copayment for laboratory services.

You have been asked to pay a $10 copayment for thyroid stimulating hormone testing. 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 thyroid stimulating hormone testing (84443).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for an outpatient hospital visit.

You asked the Plan to waive the copayment for an outpatient hospital visit. You say that you did not receive this procedure. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide medical records. Without medical records we cannot determine whether or not an outpatient hospital visit. Therefore, we decided that the Plan has to waive the copayment for an outpatient hospital visit.

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.