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

We decided that the Plan does not have to pre-approve the magnetic resonance imaging, brain, including brain stem (70551).
You asked the Plan to pre-approve the MRI. You say that you are requesting an authorization for MRI of the brain. The Plan denied your request. The Plan says this test is not medically necessary as the doctor did not indicate why the test is needed.
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 the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the member had a recent MRI of the brain. There were remote infarcts noted and white matter changes which were described as non-specific findings. The enrollee was seen for a neurology consult after completion of the MRI. However, the enrollee's history and exam were not readily consistent with MS or a similar demyelinating disease that would readily prompt repeat imaging. Furthermore, even in MS, repeat imaging is not generally done at such a short interval (3 months). For these reasons, the requested study would not be considered reasonable and 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance imaging, brain, including brain stem (70551).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from November 22, 2019, to December 26, 2019.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you disagree with how the claims were processed as the enrollee was not charged in the past. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $10 copayment for outpatient rehabilitation services provided in a specialists office or freestanding facility.
You received outpatient rehabilitation services from November 22, 2019, to December 26, 2019, for a total of 8 visits. Therefore, you are responsible to pay a $10 copayment per each visit. The total amount you owe is: $10 (copayment) x 8 (outpatient rehabilitation services) = $80. The enrollee has been asked to pay the total copayment amount of $80 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services benefit category. 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 copayments for outpatient rehabilitation services provided from November 22, 2019, to December 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for breast reconstruction surgery (19366) provided October 8, 2020.
You asked the Plan to pay for breast reconstruction surgery (19366). You say that this claim should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for breast reconstruction services (CPT 19366). The Maximus Physician Reviewer noted that CPT code 19366 is a repair or a reconstruction procedure on the breast. The operative note indicates that lumpectomy was performed on the right and an equivalent amount was removed from the left breast. A Wise Pattern reconstruction was performed. The nipple-areolar complex was reset in the skin flap. The procedure as described represents a repair and reconstruction after right breast lumpectomy and left breast reduction for symmetry.
The Plan requested a reopen and argues that when a lumpectomy procedure is closed using a Wise pattern technique and the opposite side is reduced using a Wise pattern closure, each side is considered to have been a reduction. Consequently, the "CPT code 19366-RT-AS cannot be verified." The medical records show the enrollee is a 68-year-old woman with a diagnosis of invasive ductal carcinoma of the right breast. The enrollee underwent a right oncoplastic breast reduction and a left breast reduction. The enrollee was marked in the standing position as a Wise pattern reduction. There was significant skin redundance in both breasts as the result of massive weight loss following gastric bypass surgery. All redundant skin was excised. The left superior pedicle was de-epithelialized. A similar procedure was performed on the right side. Our Medical Director has concluded that the Plan is correct in this case. The documentation does not support that a reconstruction procedure was performed, as there was no documentation of excision of tissue from another site for use in a reconstruction process. Medicare billing criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this procedure have not been met. Therefore, we decided that the Plan does not have to pay for breast reconstruction surgery (19366) provided October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the second of two resin-based composites - one surface, posterior (D2391) received February 24, 2021.

You asked the Plan to pay for the resin-based composite. You say that the Plan should cover the resin-based composite. The Plan denied your request. The Plan says the frequency limitation for this benefit was exhausted therefore, the resin-based composite is your responsibility.

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 in excess of those covered under this benefit. The Plan agreed to cover one resin-based composite on this date of service. The Plan limits coverage of resin-based composites to one procedure per calendar year. The second resin-based composite you received on this date of service is your responsibility. Therefore, we decided that the Plan does not have to pay for the second of two resin-based composites - one surface, posterior (D2391) received February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous positive airway pressure (cpap) device represented by code E0601-RR provided from October 22, 2020 to February 21, 2021.

You asked the Plan to pay for code E0601-RR. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that capped rental items are paid on a monthly rental basis.

Code E0601 is designated as a capped rental in the durable medical equipment (DME) fee schedule. The DME fee schedule also does not provide a listing for items billed with E0601-RR. As such,this item cannot be paid as billed. Code E0601-RR has not been billed with the correct modifier.Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure (cpap) device represented by code E0601-RR provided from October 22, 2020 to February 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the addition of a tooth to a partial denture (D5650) provided on March 8, 2021.
You asked the Plan to pay for the dental service. You say that a plan representative advised that because the service was medically necessary, the plan would cover 50% of the total. You also say that without this tooth you are not able to live a fulfilling life. The Plan denied your request. The Plan says the addition of a tooth to a partial denture is not listed as a covered service. The Plan also says that there is no record of a call made on April 7, 2021 or around that time.
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 addition of a tooth to a partial denture (D5650) provided on March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on December 30, 2020, by
an OON provider.
You asked the Plan to pay for the OON services. You say that it is not possible to request authorization before
services are rendered. The Plan denied your request. The Plan says services rendered by non-participating
providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan 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 nursing facility care provided on December 30, 2020, by an OON
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction and five removals of residual tooth
roots provided on March 15, 2021.
You asked the Plan to pay for the surgical extraction and removals of residual tooth roots. You say that you
assumed the practice automatically takes the extra steps to make sure procedures are covered under your
insurance. The Plan denied your request. The Plan says these services are not covered under your 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
surgical extraction and five removals of residual tooth roots provided on March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal orthotic device, by report (D7880) received November 5, 2020.
You asked the Plan to pay for the occlusal orthotic device. You say that the Plan pre-approved the requested service. The Plan denied your request. The Plan says this service is not covered under your benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the occlusal orthotic device, by report (D7880) received November 5, 2020.
Your complaint about the Plan pre-approving the service on October 1, 2020 is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from January 1, 2021, to January 31, 2021.
You asked the Plan to waive the copayment for a SNF stay. You say that you disagree with the charges because the stay was approved for 47 days. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment for days 1-20 and a $164 copayment for days 21-100 for SNF care. The enrollee received SNF care from January 1, 2021, to January 31, 2021. The record shows that they had a previous SNF stay for a total of 7 days. Therefore, they are not being charged a copayment for days 8-20
(January 1, 2021, to January 13, 2021). They are responsible to pay a $164 copayment for days 21-39 (January 14, 2021, to January 31, 2021). $164 (copayment) x 18 (SNF days) = $2,952. The enrollee has been asked to pay the total copayment amount of $2,952 for a SNF stay. A SNF stay falls within the SNF care benefit category. 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 a SNF stay provided from January 1, 2021, to January 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.
You asked the Plan to pre-approve a stair lift. You say that the enrollee has a history of peripheral neuropathy
and heart failure. The Plan denied your request. The Plan says stair lifts are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they
are not primarily medical in nature.
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe tetanus vaccine provided on January 14, 2021.You asked the Plan to pay forthe tetanus vaccine. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says a tetanus vaccine is not covered under your Medicare Part B benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the tetanus vaccine.Therefore, we decided that the Plan does not have to pay forthe tetanus vaccine provided on January 14, 2021. Benefits for the tetanus vaccinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemagnetic resonance imaging, breast, without and/or with contrast material (77049).You asked the Plan to pre-approvethe MRI. You say that you refuse to go on breast biopsy because of your current symptoms, you are requesting an MRI on your left breast.The Plandenied your request. The Plan says the requested MRI is not medically necessary.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 reviewthe case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.Our physician reviewer found in this case the patient needs a tissue diagnosis. There is no clinical rationale for the requested MRI at this time. The review has determined that the requested MRI is 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 the MRI have not been met.Therefore, we decided that the Plan does not have to pre-approvemagnetic resonance imaging, breast, without and/or with contrast material (77049).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided December 5, 2019.
You asked the Plan to pay for eyeglasses provided December 5, 2019. You say that this eyewear should be covered by the Plan. The Plan denied your request. The Plan says your $500 eyewear benefit was exhausted prior to this date of service. Maximus overturned the Plans denial because insufficient information to show exhaustion of this benefit had been provided. The Plan requested a reopen and provided the information showing the $500 benefit had been exhausted prior to the purchase of this eyewear.
Review of the additional information shows the Plan is correct in this case. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a $500 eye wear allowance for frames and lenses or contact lenses every two years.
The records submitted show you purchased eyewear on August 5, 2019 from a different provider than the one used for the December purchase. On August 6, 2019 you returned the eyewear purchased the day before for improper fit and re-order. The provider reports on September 17, 2019 you picked up the second pair ordered and those were kept. This exhausted your eyewear benefit. Therefore, we decided that the Plan does not have to pay for eyeglasses provided December 5, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health visits for physical therapy.
You asked the Plan to pre-approve the home health services. You say that you do not feel health enough to go out, especially because of the virus. You say that it is just difficult for you to get into your wheelchair and to go out. You also say that you need to work on your Achilles to make them stronger. The Plan denied your request. The Plan says there is not an order from your physician stating there is a skilled need for the requested home health physical therapy visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, there is no order from your physician for the requested services. Therefore, we decided that the Plan does not have to pre-approve home health visits for physical therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Velcro strips and a lifetime service plan provided January 11,
2021.
You asked the Plan to pay for the Velcro strips and a lifetime service plan. You say that the Velcro strips and a
lifetime service plan should be covered. The Plan denied your request. The Plan says these items are not
specifically medical in nature and are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pay for Velcro strips and a lifetime service plan provided January 11,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses provided on October 5, 2020.
You asked the Plan to pay for lumbar-sacral orthosis (L0650), shoulder elbow wrist hand orthosis, (L3960LT), and wrist hand orthosis (L3916RT). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says this provider prescribed the orthoses without a face-to-face evaluation, physical examination or imaging demonstrating medical necessity.
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 lumbar-sacral orthosis (L0650), shoulder elbow wrist hand orthosis, (L3960LT), and wrist hand orthosis (L3916RT). Our reviewer says that the orthoses are not medically necessary. 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 an LSO 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 an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back. The documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the shoulder. The documentation in the case file does not support that the requested wrist/hand orthosis was medically reasonable and necessary for the enrollee in this case. An appropriate history and a physical examination of the wrist would reasonably be required to adequately assess whether the wrist/hand orthosis was medically reasonable and necessary. The documentation does not support that the wrist/hand orthosis was medically reasonable and necessary in this case, as there is insufficient documentation of a credible physical examination of the wrist. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar-sacral orthosis (L0650), shoulder elbow wrist hand orthosis,
(L3960LT), and wrist hand orthosis (L3916RT) have not been met. Therefore, we decided that the Plan does not have to pay for the orthoses provided on October 5, 2020.