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

We decided that the Plan does not have to waive the copayment forthe podiatry services rendered on August 26, 2020.You asked the Plan to waive the copayment forthese services. You say that you saw the nurse practitioner.The Plan denied your request. The Plan says the copayment 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). Your contract with the Plan clearly says that you must pay a $40 copayment for each Medicare-covered podiatry visit. Review of the file shows that you received podiatry services on August 26, 2020. The copayment applies to the visit whether you see a podiatrist or a nurse practitioner. You have been asked to pay a $40 copayment for these services. These services fall within the Medicare-covered podiatry 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 forthe podiatry services rendered on August 26, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is receiving active care and increased monitoring for symptomatic CoViD-19 while at her long-term care (LTC) facility. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted.Therefore, we decided that the Plan has to pre-approveskilled nursing facility (SNF) care.
If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again ifwe 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for an outpatient surgery provided by a participating provider on September 28, 2020.You asked the Plan to reduce the coinsurance foran outpatient surgery. You say that this should be a $450 copayment. The Plan denied your request. The Plan says the correct coinsurance 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 20 % coinsurance for outpatient surgery. You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total allowed amount is $5,337.98. The total amount you are being asked to pay is $1,067.60 ($5,337.98 x 20% = $1,067.60). The correct copayment coinsurance has been applied to the surgery that was provided. An outpatient surgery falls within the outpatient surgery 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 reduce the coinsurance for an outpatient surgery provided by a participating provider on September 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing facility (SNF) care provided on July 27, 2020, through July 31, 2020.You asked the Plan to pay forSNF care. You say that the services were medically necessary.The Plan denied your request. The Plan says the enrollee has no daily skilled nurse or therapy needs.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found there were no identifiable skilled nursing service needs and the beneficiary did not require skilled nursing or therapy services on a daily basis.This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Specifically, the services were not medically necessary or reasonable for this patient.Therefore, we decided that the Plandoes not have to pay forskilled nursing facility (SNF) care provided on July 27, 2020, through July 31, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hospital care (99235) provided on September 1, 2019.You asked the Plan to pay forthe hospital care. You say that you would like reconsideration because you were not given timely information regarding the member's benefits.The Plan denied your request. The Plan says this claim was filed past the 12 month timely filing deadline.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the hospital care was not filed until September 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe hospital care (99235) provided on September 1, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe TENS lead rendered on September 3, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that replacement of lead wires (A4557) more often than every twelvemonths would rarely be reasonable and necessary.We looked at the file and Medicare rules. The file shows that the TENS device was rendered on August 3, 2020. Replacement lead wires more often than every twelvemonths is not necessary.Therefore, we decided that the Plan does not have to pay forthe TENS lead rendered on September 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for360 zinc air batteries (L8621) provided on February 26, 2020.You asked the Plan to pay for360 zinc air batteries. You say that the enrollee requires 120 units a month.The Plan denied your request. The Plan says the billed units exceed what is allowed for this item.The Plan must follow Medicare rules. Medicare rules say that the Battery Quantity Limit Per Implant for L8621 is 30 per month.We looked at the file and Medicare rules. The record shows that 180 units of L8621 were provided on May 16, 2019, 180 units were provided on August 26, 2019, and 60 units were provided on November 27, 2019. This means in the 7-month period prior to the date of service at issue, 420 units were provided, 60 units for each of the seven months. The 360 units provided on the date of service at issue therefore exceed the Quantity Limit of 30 per month. Based on this information, we decided that Medicare rules for coverage of 360 zinc air batteries have not been met.Therefore, we decided that the Plan does not have to pay for360 zinc air batteries (L8621) provided on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 6, 2020, by an OON provider.You asked the Plan to pay fora psychiatric diagnostic evaluation and a blood draw. You say that the provider is in-network with the Plan since 2017 but has not updated information in the records.The Plan denied your request. The Plan says rules for payment have not been met.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 forthe medical services provided on May 6, 2020, by an OON provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve platelet rich plasma injections.
You asked the Plan to pre-approve these services. You say that you need the services due to damage from
chemotherapy. The Plan denied your request. The Plan says the 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the submitted records show that you
have bone disease of the jaw after chemotherapy. The use of platelet rich plasma injections is considered
experimental/investigational in nature at this time. More research is needed to confirm the benefit for your
condition. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve platelet rich plasma injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Genesight Psychotropic Assay rendered on July 24, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan must follow Medicare rules. The rules say that GeneSight testing may only be ordered by licensed psychiatrists or neuropsychiatrists.We looked at the file and Medicare rules. The file shows that the testing was ordered by a family medicine physician. 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 forthe Genesight Psychotropic Assay rendered on July 24, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe imaging services (Q0092, R0075) provided on July 21, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services are not payable.The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The services in question werebilled with POS 31. These services are not separately payable for POS 31. If the services were billed with the wrong POS code, then a new claim must be submitted. Based on this information, we decided that Medicare rules for coverage of the services have not been metTherefore, we decided that the Plan does not have to pay forthe imaging services (Q0092, R0075) provided on July 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe x-ray services provided on September 14, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe x-ray services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered 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 requestedprovider 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 forthe x-ray services provided on September 14, 2020, by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that there is no clinical advantage of LTACH over acute hospital.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pay for non-emergent vision services provided in India from January 27, 2020, to March 9, 2020.

You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says these were outpatient vision services that were not provided in an emergent or urgent situation out of the country. Maximus overturned the Plans decision. The Plan requested a reopen and stated that outpatient physician services and lab services for cataract consultation are not considered emergent or urgent services needed to stabilize a life-threatening condition. 

The Plan is correct in this case. 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 only urgent or emergent services to stabilize a life-threatening event are for covered worldwide. Vision services provided in India for the evaluation of cataracts are not considered to be urgent or emergent services out of the country. Therefore, we decided that the Plan does not have to pay for non-emergent vision services provided in India from January 27, 2020, to March 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex Superion device for the enrollee.You asked the Plan to pre-approvethese services. You say that these services are medically necessary.The Plan denied your request. The Plan says that experimental and investigational procedures are not covered by Medicare.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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The spacer is experimental. More research is needed to show safety and efficacy. There is no instability. Hardware is not needed. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea Vertiflex Superion device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete maxillary denture, immediate mandibular denture, endosteal implants, alveoloplasties not in conjunction with extractions, and prefabricated abutments provided on February 20, 2020, and July 1, 2020.You asked the Plan to pay forthe complete maxillary denture, immediate mandibular denture, endosteal implants, alveoloplasties, and prefabricated abutments. You say that a Plan representative advised that you have a $1,000 deductible, and then everything would be covered at 100%.The Plan denied your request. The Plan says the annual limit allowed by your dental plan for the benefit year had been paid. The Plan also says that thenon-contracted provider was correctly advised that you had a $1,000 maximum benefit for dental services, and you would be responsible for any amount over the $1,000 maximum.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 Plan offers a $1,000 allowance every year for Non-Medicare covered preventive and comprehensive dental services combined. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit on February 20, 2020 and your annual maximum benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forthe complete maxillary denture, immediate mandibular denture, endosteal implants, alveoloplasties not in conjunction with extractions, and prefabricated abutments provided on February 20, 2020, and July 1, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation and additional 
intraoral periapical x-ray provided on September 30, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and additional intraoral periapical x-
ray. You say that your mouth was swollen, and you were in pain. You also say that the dentist took x-rays and 
sent you to a surgeon who pulled your tooth. The Plan denied your request. The Plan says the problem focused 
limited oral evaluation is not covered. The Plan also says that your benefits for the additional intraoral 
periapical x-ray have been satisfied and the frequency limitation had been exceeded. 
 
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 problem focused limited oral 
evaluation is not among those covered under this benefit. The contract also says that intraoral x-rays are limited 
to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on 
September 30, 2020, and your intraoral x-rays benefit had been exhausted. Therefore, we decided that the Plan 
does not have to pay for the problem focused limited oral evaluation and additional intraoral periapical x-ray 
provided on September 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 20, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the laboratory. 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 August 20, 2020.