Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided to the enrollee from August 1, 2019 to August 28, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there was no evidence of urgent/emergent care identified.
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 has network providers available who can provide 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 physical therapy services provided to the enrollee from August 1, 2019 to August 28, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Ilumya.
You asked the Plan to pre-approve Ilumya. You say that this drug is covered for the enrollee's diagnosis, and the enrollee has previously been treated with methotrexate and folic acid which were not successful. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Remicade or Inflectra and Stelara before it will approve Ilumya.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Ilumya. Our reviewer says that the enrollee does not meet the criteria for use of Ilumya. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Remicade or Inflectra and Stelara. The documentation submitted does not support that these drugs would likely be less effective or have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Ilumya.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on December 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 has network providers available who can provide 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 subsequent nursing facility care services provided on December 17, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total knee arthroplasty.
You asked the Plan to pre-approve total knee arthroplasty. 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 follows Medicare rules. Medicare rules say that total knee arthroplasty is only covered for certain 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 total knee arthroplasty. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee underwent a right total knee replacement in November 2018. The enrollee subsequently developed an infection requiring removal of the implant and multiple surgical incision and drainage procedures. The most recent physician report in the submitted medical records is dated February 4, 2020 and indicated that the enrollee was not ready for surgery due to smoking status. There is no detailed documentation, including laboratory reports, relative to the current status of the enrollee's infection or a physician note indicating that it is appropriate to proceed with surgery. In the absence of this documentation, Medicare coverage criteria have not been met to support the requested right revision total knee replacement. Therefore, the enrollee does not have a diagnosis, condition, and/or symptoms that meets the criteria for coverage of right revision total knee replacement, and this procedure would not be considered 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 total knee arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve total knee arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a nurse practitioner on January 4, 2020.
You asked the Plan to waive the copayment for specialist services. You say that you were told that you would only be charged for a primary care physician visit. 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 $40 copayment for physician/practitioner services/specialist visit. You have been asked to pay a $40 copayment for specialist services. The Plan says that the nurse practitioner is not credentialed with the Plan. Specialist services fall within the physician/practitioner services/specialist visit 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 provided by a nurse practitioner. on January 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Celecoxib and Acetaminophen provided on December 4, 2019.
You asked the Plan to pay for the Celecoxib and Acetaminophen. You say that you were given a drug that you did not ask for or want. You also say that they suggested you take the pill for the pain after surgery. The Plan denied your request. The Plan says these are self-administered drugs and are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Celecoxib and Acetaminophen provided on December 4, 2019.
Benefits for Celecoxib and Acetaminophen may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blood ketone test strips.
You asked the Plan to pre-approve blood ketone test strips. The Plan denied your request. The Plan says that the blood nor urinalysisketone test strips meet the definition of durable medical equipment.
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 blood ketone test strips. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. While the testing of a patient's ketones may be warranted during an acute illness or if there is diagnostic uncertainty, routine home monitoring of ketones, especially for type II diabetics, who are not predisposed to diabetic ketoacidosis, is not considered the standard of care. Our physician reviewer found that your condition does not meet criteria for coverage of blood ketone test strips. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of blood ketone test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve blood ketone test strips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an X-Ray examination provided on December 13, 2019.
You asked the Plan to waive the coinsurance for X-Ray exam. You say that you were told you would have to pay $0 for this test. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.
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 50% coinsurance for out-of-network X-Ray. The allowed amount of this claim is $105.15, resulting in a coinsurance obligation of $52.58. You have been asked to pay 50% coinsurance for X-Ray exam. X-Ray exam 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 coinsurance for an X-Ray examination provided on December 13, 2019.
Your complaint regarding receiving inaccurate information about the cost-share for this service is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the MRI provided on September 10, 2019.
You asked the Plan to pay for the MRI. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are a duplicate to a previously processed claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 72158 is magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar. We find that CPT code 72158 is not supported in the medical record. Specifically, this code for this date of service has already been processed and paid by the plan. Therefore, this claim is a duplicate. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pay for the MRI provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 1, 2019, to August 31, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 1, 2019, to August 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve another set of diagnostic facet injections.
You asked the Plan to pre-approve the diagnostic facet injections. You say that you are in pain and the requested injection services are medically necessary. The Plan denied your request. The Plan says the records provided do not show that the enrollee experienced 80% relief or greater of her primary index pain that lasted a time period consistent with the local anesthetic used. The Plan says that it is documented that the enrollee did not have significant pain relief after the first injection.
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 diagnostic facet injections. Our reviewer says that the injections being requested are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no relief from the first set of diagnostic blocks. Therefore, the test was negative. The facets are not the probably gain generators and the block should not be repeated. 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 diagnostic facet injections have not been met. Therefore, we decided that the Plan does not have to pre-approve another set of diagnostic facet injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on January 29, 2020.
You asked the Plan to pay for the dental service. You say that you were not advised that this type of x-ray was not covered. You say that you knew you were only able to get 1 x-ray per year. You also say that you thought that is what you were getting. The Plan denied your request. The Plan says the panoramic x-ray 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 panoramic x-ray is not among those covered under this benefit. The Evidence of Coverage clearly states that bitewing x-rays are the only dental x-ray that is covered by the Plan. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on January 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that an inpatient admission is generally appropriate when the admitting physician expects the patient to need hospital care that crosses at least two midnights. The expectation should be based on such complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and medical risk. The factors must be documented in the medical record. If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as "inpatient only" is generally appropriate, regardless of the length of stay. An inpatient admission may be appropriate if the admitting physician expects a patient to require hospital care for only a limited period of time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be supported by the medical record. You can find this rule at 42 CFR Section 412.3.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. 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. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 15, 2019 to October 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on August 14, 2019.
You asked the Plan to pay for the drug testing. 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 supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include an order for 22 or more drug classes. The lab order submitted indicates only six drugs were requested. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on August 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions (D7140) and the bone replacement grafts (D7953) provided on March 4, 2019.
You asked the Plan to pay for the extractions (D7140) and the bone replacement grafts (D7953). You say that the plan booklet says extractions should be paid for under the Plan. You say you would like to be reimbursed. The Plan denied your request. The Plan says services done by an out-of-network dentist 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, out-of-network services are not among those covered under this benefit. The record shows that the provider is out-of-network. Therefore, we decided that the Plan does not have to pay for the extractions (D7140) and the bone replacement grafts (D7953) provided on March 4, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from September 4, 2019 to September 27, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claims were not billed correctly.
The Plan must follow Medicare rules. The rules say that home health claims must be billed with a FIPS code. We looked at the file and Medicare rules. The file shows that the claims were not billed with the required FIPS code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from September 4, 2019 to September 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone tablets.
You asked the Plan to pre-approve the Prednisone tablets. The Plan denied your request. The Plan says Medicare Part B does not cover drugs that are usually self-administered by the enrollee.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prednisone tablets.
Benefits for Prednisone tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient surgery services rendered on August 26, 2019 and August 27, 2019.
You asked the Plan to waive the copayments for these services. You say that you should not be assessed a copayment. The Plan denied your request. The Plan says the copayments were applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for in-network surgery services.
Review of the file shows that you received outpatient surgical services on August 26, 2019 and August 27, 2019. You have been asked to pay a $100 copayment per date of service for these services, for a total of $200. These services fall within the in-network surgery 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 copayments for the outpatient surgery services rendered on August 26, 2019 and August 27, 2019.