Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2311).
You asked the Plan to pre-approve an expandable controller (E2311). You say that the requested expandable controller (E2311) is medically necessary. The Plan denied your request. The Plan says the requested expandable controller (E2311) is 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 an expandable controller (E2311). Our reviewer says that the requested expandable controller (E2311) is not medically necessary. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities supports that the enrollee can control any power options through their own individual switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller (E2311) have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, add tooth to existing partial denture, panoramic x-ray, add clasp to existing partial denture, prophylaxis, periodic oral evaluation, and resin-based composite provided from January 14, 2021, to February 10, 2021 by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation, add tooth to existing partial denture, panoramic x-ray, add clasp to existing partial denture, prophylaxis, periodic oral evaluation, and resin-based composite. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services were rendered by a non-contracted provider. The Plan also says that no benefits are available for procedures performed by OON providers.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, add tooth to existing partial denture, panoramic x-ray, add clasp to existing partial denture, prophylaxis, periodic oral evaluation, and resin-based composite provided from January 14, 2021, to February 10, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the dental services provided from June 18, 2019, to December 2, 2020.

You asked the Plan to reimburse you for the dental services. You say that you are not able to drive outside of your area. You say that there are no in network dentists available in your area. You say that the plan confirmed this. You also say that a plan representative advised that it is possible an exception may be made. The Plan denied your request. The Plan says the dental services you received from June 18, 2019, to November 26, 2019 are not covered. The Plan says that the claim for these dates of service were not submitted until after the allowed 12-month timeframe. The Plan says that the provider in this case is out of network. The Plan says that dental services performed out of network are not covered. The Plan also says that there is no record of a call to verify benefits or provider eligibility prior to the dates of service.

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. Additionally, 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. 

The record shows that a claim for dental services provided from June 18, 2019, to November 26, 2019 was not filed until December 2, 2020. This means that more than one calendar year from the date of service has passed since the claim was filed. Additionally, though the Plan offers a dental benefit in excess of Medicare coverage, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the dental services provided from June 18, 2019, to December 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skin removal (15832).

You asked the Plan to pre-approve the skin removal. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the supplied physical examination notes do not document chronic infection, inflammation or ongoing necrosis post three (3) months of appropriate therapy.

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 skin removal. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the photographs submitted for review are of poor quality and the records are insufficient to establish medical necessity. 

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 skin removal have not been met. Therefore, we decided that the Plan does not have to pre-approve the skin removal (15832).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist office services provided on October 12, 2020.

You asked the Plan to waive the copayment for the specialist office services. You say that the doctor never examined you, and you never took off your coat. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file show that you received specialist office services provided on October 12, 2020, from an in-network provider. You were asked to pay a $25 copayment for the in-network specialist office services. Your 2020 contract says that enrollees must pay a $25 copayment for each in-network specialist visit for Medicare-covered benefits. 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 office services provided on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an office visit provided on January 14, 2021.
You asked the Plan to waive the coinsurance for office visit. You say that you were told by the provider that they are in-network with the Plan. 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 40% coinsurance for out-of-network primary care visit. The allowed amount of the claim is $266, resulting in a coinsurance obligation of $106.40. You have been asked to pay 40% coinsurance for office visit. Office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an office visit provided on January 14, 2021.
Your complaint regarding receiving inaccurate information about the network status of this provider 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 chest x-ray (71046) provided on August 30, 2020.

You asked the Plan to pay for the chest x-ray (71046). You say that the chest x-ray (71046) provided on August 30, 2020 was medically necessary. The Plan denied your request. The Plan says the chest x-ray (71046) provided on August 30, 2020 was 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 pay for the chest x-ray (71046). Our reviewer says that the chest x-ray (71046) provided on August 30, 2020 was not medically necessary. Our physician reviewer found in this case; the enrollee received a chest x-ray based upon diagnostic code F17.200 nicotine dependence. No other medical records to substantiate the medical necessity or reasonableness as defined by Medicare rules are submitted. The elements of the coverage rule are not satisfied. The requested service cannot be recommended. 

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 chest x-ray (71046) have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71046) provided on August 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on November 20, 2020.
You asked the Plan to reimburse you for the eyeglasses. You say that you needed the eyeglasses because the
previous pair of eyeglasses were broken. The Plan denied your request. The Plan says the vision benefit
maximum has been reached.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services every year.
We looked at the file and the Plan's rules. The file shows that you received the eyewear benefit on
January 17, 2020, and vision benefit maximum has been reached. Therefore, we decided that the Plan does not
have to reimburse you for eyeglasses provided on November 20, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the bilateral sacroiliac joint injection.
You asked the Plan to pre-approve the bilateral injection. You say that you would like reconsideration because the member had a prior injection with which they experienced relief. The Plan denied your request. The Plan says that the documentation does not establish 75% relief from the prior injection.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 bilateral injection. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found this is a therapeutic injection. It is not unusual for a member to be unable to delineate the degree and duration of pain relief. 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 bilateral injection have been met. Therefore, we decided that the Plan has to pre-approve the bilateral sacroiliac joint injection.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea.
You asked the Plan to pre-approve Eylea. You say that the requested Eylea is medically necessary. The Plan
denied your request. The Plan says the enrollee must try and fail compounded Avastin first.
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 Eylea. Our reviewer says that the Plan's
step therapy criteria have not been met. Our physician reviewer found in this case; the enrollee has age related
macular degeneration. The requested medicine is a new start. The record does not indicate that the enrollee has
tried and failed or has a contraindication to, the plan's preferred step one agent. The elements of the coverage
rule are not satisfied. The requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to
pre-approve Eylea.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring (95941) provided on November 27, 2020.

You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this procedure code is not compensable under Medicare.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 95941 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 95941 has a status indicator of I. This means that CPT code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the continuous intraoperative neurophysiology monitoring have not been met. Therefore, we decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring (95941) provided on November 27, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient psychiatric care provided on September 4, 2020, by an OON provider.

You asked the Plan to pay for outpatient psychiatric care. You say that the requested medically necessary services were rendered to the enrollee in good faith. The Plan denied your request. The Plan says rules for OON care 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 for outpatient psychiatric care provided on September 4, 2020, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CustomNext Cancer + RNAinsight testing for the enrollee.

You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary based on the stage of the cancer.

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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has Stage 1A grade 1 endometrial cancer diagnosed in 2019, treated with hysterectomy and now with no evidence of disease. The medical records do not indicate that the testing would directly impact the enrollee's management.

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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve CustomNext Cancer + RNAinsight testing for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve screening test provided during a wellness exam for the enrollee on October 12, 2020, by a non-participating provider.

You asked the Plan to pre-approve the services. You say that the services were medically necessary. The Plan denied your request. The Plan says Medicare guidance says screening testing is not a Medicare benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the services, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve screening test provided during a wellness exam for the enrollee on October 12, 2020, by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on February 27, 2020.
You asked the Plan to pay for drug testing. You say that this should be covered. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that services are covered 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 monitor. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is on three shots per day, and does would be adjusted if there was more blood glucose data. Apparently, she cannot check blood glucose levels due to calluses on the fingers, making it difficult to use a glucometer. This is an ideal patient for the requested monitor.

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 monitor have been met. Therefore, we decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2393) provided on December 22, 2020.

You asked the Plan to pay for the dental service. You say that based on the description of benefits given in your policy manual, fillings and other procedure are covered at 100$ up to $2,000. You say that had you been aware that only 2 fillings would be covered per calendar year, you would have waited until January 2021. You also say that this should be covered due to the failure to disclose the limitations to you. The Plan denied your request. The Plan says 2 fillings per calendar year are covered. The Plan also says that the frequency limit has 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 and filling is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for 2 fillings that you received on May 14, 2020. Therefore, we decided that the Plan does not have to pay for the filling (D2393) provided on December 22, 2020.