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

We decided that the Plan does not have to pre-approve Gammagard for the enrollee.

You asked the Plan to pre-approve Gammagard. You say that Gammagard is medically necessary. The Plan denied your request. The Plan says that per review of the medical literature, the clinical value and effectiveness of IVIG in the setting of sarcoidosis, small fiber neuropathy associated with sarcoidosis, sarcoid related polyneuropathy, and neurosarcoidosis has not been demonstrated in the peer-reviewed literature.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Gammagard. Our reviewer says that Gammagard is not medically reasonable and necessary for the enrollee. The enrollee has a diagnosis of sarcoidosis with the original diagnosis in the 1980's who was treated with Prednisone and went into remission. Current organ involvement includes the lungs and skin along with small fiber neuropathy which developed three and a half years ago. There is now a request for intravenous immunoglobin (IVIG) therapy with Gammagard. IVIG therapy is not supported for the enrollee's diagnosis of Sarcoidosis. Per the reviewed literature, the clinical value and effectiveness of IVIG in the setting of sarcoidosis, small fiber neuropathy associated with sarcoidosis, sarcoid related polyneuropathy, and neurosarcoidosis has not been demonstrated. The requested use of Gammagard is not FDA-approved for the enrollee's diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for Gammagard. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gammagard have not been met. Therefore, we decided that the Plan does not have to pre-approve Gammagard for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tempurpedic mattress to be purchased from a local store.
You asked the Plan to pre-approve the mattress. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says you went to a public store and ordered the mattress.
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. The records show you went to a public store and ordered the mattress. The mattress is not durable medical equipment (DME) or medical in nature. The item was not provided by a DME supplier. Therefore, we decided that the Plan does not have to pre-approve Tempurpedic mattress to be purchased from a local store.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for a cardiovascular stress test with rubidium contrast material, aminophyllin (a Medicare Part B drug), and regadenoson (a Medicare Part B drug) provided on October 26, 2020.
You asked the Plan to waive the cost-sharing for stress test, imaging contrast supplies, and Part B drugs. You say that testing was unnecessary, and you do not feel you should have to pay this additional cost-sharing. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are 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 $20 copayment for stress test and 20% coinsurance for imaging supplies and Part B drugs. The allowed amounts of the imaging supplies and Part B drugs total $1,285.53, resulting in a total coinsurance amount of $257.10. Your total cost-sharing amount is therefore $277.10. You have been asked to pay $20 copayment for stress test and 20% coinsurance for imaging supplies and Part B drugs. Stress test, imaging contrast supplies, and Part B drugs fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and "Medicare Part B Prescription Drugs" benefit categories. 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 cost-sharing for a cardiovascular stress test with rubidium contrast material, aminophyllin (a Medicare Part B drug), and regadenoson (a Medicare Part B drug) provided on October 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on October 6, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, POS 11.
The Plan must follow Medicare rules. Medicare rules say that that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the submitted claim was billed with a laboratory place of service code while the record indicates the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided on October 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided to you from July 9, 2020, to December 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says services are not covered for this type of provider.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided to you from July 9, 2020, to December 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional trips for routine transportation (A0100).

You asked the Plan to pre-approve additional trips. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says you have exhausted the allowable transportation benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional trips for routine transportation (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM)
and supplies.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says you do not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific
criteria are met.
We looked at the file and Medicare rules. The records show that you do not treat with at least three insulin
injections per day and are not using a continuous insulin infusion pump. 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 a Freestyle Libre continuous glucose monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiac rehabilitation provided by an out-of-network provider from December 2, 2020, through December 28, 2020.

You asked the Plan to pay for the cardiac rehabilitation. You say that the medical records warrant the medical necessity of the service billed and the claim should be reprocessed for payment. The Plan denied your request. The Plan says prior authorization was required but not obtained.

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 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 cardiac rehabilitation provided by an out-of-network provider from December 2, 2020, through December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-Ray examination provided by a chiropractor on April 23, 2020.

You asked the Plan to pay for X-Ray. You say that you are requesting payment for this service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because an X-Ray is not covered by Medicare or the Plan when performed by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for an X-Ray examination provided by a chiropractor on April 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) and core build up (D2950) for tooth # 15.
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied your request. The Plan says porcelain crown is not listed as a covered service. The Plan says that core build up is not listed as a covered service either.
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 pre-approve a porcelain crown (D2740) and core build up (D2950) for tooth # 15.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing (D4342) for the upper left and lower left quadrants.
You asked the Plan to pre-approve the dental services. You say that the dentures were approved. You say that you were not able to get them within the approved time period because of Covid-19. You also say that you still need new dentures. The Plan denied your request. The Plan says scaling and root planing is covered once per 36 months per quadrant. The Plan also says that the frequency limit for this service has been reached for the upper left and lower left quadrants.
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 and scaling and root planing is listed as a covered service, the frequency limit has been reached. The record shows that the Plan paid for this service for the upper left and lower left quadrants that you received on May 17, 2019. Therefore, we decided that the Plan does not have to pre-approve scaling and root planing (D4342) for the upper left and lower left quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and an extraction (D7210).

You asked the Plan to pre-approve a comprehensive oral evaluation, and an extraction. You say that the services are necessary, and you want the Plan to cover them. The Plan denied your request. The Plan says dental services performed by an oral surgeon are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Specifically, the request is for the services to be rendered with an oral surgeon. Services must be performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and an extraction (D7210).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve a power scooter. You say that without a scooter, you are forced to cancel numerous medical appointments. The Plan denied your request. The Plan says a home evaluation was not provided.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99213) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you are appealing for continuity of care because you have been seeing this oncologist for the past 10 years. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the outpatient office visit (99213) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implants, including preparation of the jaw and extractions.
You asked the Plan to pre-approve the implant services. You say that these services are necessary and should be covered. The Plan denied your request. The Plan says these services are not covered by the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental implants, including preparation of the jaw and extractions.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve the additional routine transportation. You say that you would like reconsideration because this transportation is necessary for the member to continue physical therapy. The Plan denied your request. The Plan says the member has exhausted their routine transportation benefit for 2021.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a denture adjustment (D5455) and sales tax (D9985).
You asked the Plan to pre-approve the dental services. You say that a plan representative advised that this provider was in network. You say that you were told that you may need to pay sales tax. You also say that you went in for an adjustment but are still having problems. The Plan denied your request. The Plan says denture adjustment is not listed as a covered service. The Plan says that sales tax is not listed as a covered service either.
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 pre-approve a denture adjustment (D5455) and sales tax (D9985).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on July 17, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says you are not eligible to bill Medicare covered enrollees. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information which confirms you are not eligible to bill the enrollee or the Plan.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who is not eligible to bill Medicare. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on July 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).

You asked the Plan to pre-approve a pneumatic compression device. You say that with uncontrolled lymphedema swelling due to being denied appropriate treatment, the enrollee is likely to experience worsening symptoms. The Plan denied your request. The Plan says the clinical information provided shows the enrollee only has B/L LE lymphedema not extending to abdomen or pelvic area therefore the criteria is not met.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. A PCD coded as E0652 is not covered for the treatment of lymphedema of the extremities alone even if the criteria in this section are met. Claims will be denied as not reasonable and necessary.

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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aluminum rigid removable side guards for a wheelchair.
You asked the Plan to pre-approve these 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 for equipment to be covered, it must primarily serve a medical purpose. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Side guards are also used for use outside of the home, and Medicare does not cover equipment for this use. Therefore, we decided that the Plan does not have to pre-approve aluminum rigid removable side guards for a wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on June 25, 2020.
You asked the Plan to waive the copayment for an endoscopy procedure. You say that are being overcharged for this. You say that this was a diagnostic procedure. 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 $260 copayment for outpatient surgery/in-network. You have been asked to pay a $260 copayment for an endoscopy procedure. The correct copayment has been applied to the services that were provided. An endoscopy procedure 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 an outpatient surgery provided by a participating provider on June 25, 2020.