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

We decided that the Plan does not have to pay for anesthesia services provided to the enrollee and billed under "claim A" with CPT 00812- QX.

You asked the Plan to pay this claim. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim denied because it was previously paid under a separate claim number. The Plan included the Explanation of Benefits for the referring claim that shows the Plan previously paid $382.24 for this service which processed under "claim B".

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services appropriately. In this case, the claim in question or "claim A" cannot be paid as billed because the Plan has provided documentation to show this service was already paid and billed under "claim B". Based on this information, we decided that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services provided to the enrollee and under code 00812-QX.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a home blood glucose monitor.

You asked the Plan to provide coverage for this item. You say that this equipment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for a home blood glucose monitor are not met. Maximus overturned the Plans denial because medical records had not been submitted for review. The Plan requested a reopen and provided the required medical records.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare only covers a home blood glucose monitor for enrollees with a diagnosis of diabetes who need specific diabetic management. The medical records show your most recent lab work indicates you are not in diabetic range. The physician notes from your annual wellness exam state "mild" elevation of fasting sugar level and a low sugar and/or low carb diet was suggested. The medical records do not show you are being treated for diabetes. Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have to provide coverage for a home blood glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device and accessories (E0651,
E0667) provided December 19, 2019, by an out-of-network (OON) provider.
You asked the Plan to pay for the pneumatic compression device and accessories. You say that this device was
medically necessary for the enrollee. The Plan denied your request. The Plan says prior authorization has not
been met.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of these services have not been met. Specifically, there were no medical records provided in this case.
Without the medical records, we cannot review to see if the services were urgent/emergent or medically
necessary. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and
accessories (E0651, E0667) provided December 19, 2019, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for COVID-19 testing received on December 1, 2020.
You asked the Plan to pay for the services. You say that this was required by your employer. The Plan denied your request. The Plan says that this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan has not substantiated their denial. The contract denies drug testing when required for employment, but COVID-19 testing is not drug testing. There is nothing specific in the contract that denies this sort of testing. Therefore, we decided that the Plan has to pay for COVID-19 testing received on December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove the power wheelchair accessory, power seat elevation (E2300).

You asked the Plan to preapprove the power wheelchair accessory. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee meets the Medicare criteria for the appealed Group 3 PWC and Accessories with the exception of seat elevation feature, as this feature does not serve a primary medical function.

The Plan must follow Medicare rules. The rules say that a device that is not medical in nature is not covered. A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. Therefore, we decided that the Plan does not have to preapprove the power wheelchair accessory, power seat elevation (E2300).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device (CPT code 22869), for the
enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the services are considered experimental and investigational.
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 services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex spacer device remains experimental for use in spinal surgery. More research is
needed to show safety and efficacy of the device. Open laminectomy decompression is the gold standard
procedure for spinal stenosis decompression. The Vertiflex device is not medically needed in this case as there
is no clear instability demonstrated and it is experimental.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex Superion device (CPT code 22869), for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmic ultrasound.

You asked the Plan to waive the copayment for the ophthalmic ultrasound. You say that you shouldn't have to pay a copayment for this service because it should be included in your diabetic vision screening benefit. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($22.17) is less than your copayment obligation, you are responsible for the full 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). Your contract with the Plan clearly says that you must pay a $50 copayment for x-rays and ultrasounds.

You have been asked to pay a $50 copayment for the ophthalmic ultrasound. the ophthalmic ultrasound falls within the x-rays and ultrasounds benefit category. Your EOC does not say that ophthalmic ultrasounds are part of your glaucoma screening benefit. 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 the ophthalmic ultrasound.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Nivestym (G-CSF Filgrastim).
You asked the Plan to pre-approve Nivestym. You say that the enrollee has a covered diagnosis for Nivestym. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the requested off-label use of Nivestym is not medically accepted.
The Plan follows Medicare rules. Medicare rules state that Nivestym may be covered for certain indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Nivestym. Our reviewer says that the enrollee does not meet the Medicare criteria for use of Nivestym. Our physician reviewer found the enrollee has pancytopenia related to cirrhosis with splenomegaly. Absolute neutrophil count is 1600 and there is no documentation of recurrent infections. There is no indication for the use of growth factors to increase her white blood cell count. This service 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 Nivestym have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Nivestym (G-CSF Filgrastim).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam.

You asked the Plan to pay for the amalgam. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 amalgam.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee can adequately receive the care needed for ongoing ventilator weaning in the current location. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus vaccine and administration.

You asked the Plan to pay for the tetanus vaccine and administration. You say that the provider is charging an incorrect amount. The Plan denied your request. The Plan says the records do not state the tetanus vaccine was provided in relation to a disease or injury.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccine and administration. 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 and administration. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine and administration.

Benefits for the tetanus vaccine and administration may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.

Please note, the Plan has confirmed that the provider has corrected the issue and the enrollee is only responsible for $37 for the uncovered immunization.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic office visit.

You asked the Plan to pay for the chiropractic office visit (99212). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the service is not a covered benefit.

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 the chiropractic office visit.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for a second chest x-ray, provided to the enrollee on July 8, 2020 and billed under claim A for code 71045-26-77.
You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested are reopen and stated that claim A denied because they previously paid for this service under claim B. The medical records do not support why this procedure had been rendered twice on the same day. The Medicare guidance says a second interpretation is only paid under unusual circumstances (for which documentation is provided). The records provided do not contain such documentation.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when necessary provide the required medical records to support the services billed. The records do not clarify as to why this second service was required on the same day or give any specific reason that would allow Medicare payment. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for a second chest x-ray, professional component provided to the enrollee on July 8, 2020 and billed under (claim A) for CPT 71045-26-77.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the addition of a tooth to an existing partial denture (D5650) provided on December 2, 2020.
You asked the Plan to pay for the dental service. You say that you need this service for medical reasons, not a cosmetic replacement. You say that there is more tooth that needs to be removed. You say that you have diabetes. You say that your teeth are getting bad. You also say that you cannot afford to pay all of that. The Plan denied your request. The Plan says you pay 100% for Class 3 Major Services. The Plan also says that adding teeth to existing partial denture is listed as a Class 3 Major Service.
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 addition of a tooth to an existing partial denture is listed as a Class 3 Major Service. The Evidence of Coverage clearly states that you pay 100% for Class 3 Major Services. Therefore, we decided that the Plan does not have to pay for the addition of a tooth to an existing partial denture (D5650) provided on December 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
While the medical record supports a need for physical and/or occupational therapy, there is no documented
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve crowns (D2752) for tooth #'s 7 and 10.
You asked the Plan to pre-approve the crowns. You say that the enrollee does not have subcrestal caries and can maintain crowns for at least 5 years. The Plan denied your request. The Plan says that the review of the submitted dental records does not meet the requirement for this crown, because of the type of cavities that these teeth have.
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 Plan covers the crowns when the services are medically necessary and reasonable. 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 crowns. Our reviewer says that the crowns are medically reasonable and necessary. Our physician reviewer found the x-rays show heavily restored teeth along with what appears to be some abrasion/attrition lesions. The current restorations are above the level of the bone, and there is no apparent decay seen at or below the level of the bone. Our reviewer found that the teeth have at least 50% structural damage from decay or prior restoration. Our physician reviewer also found that there is sufficient missing structure on both teeth such that the additional strength required for function would be achieved by the use of a crown. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have been met. Therefore, we decided that the Plan has to pre-approve crowns (D2752) for tooth #'s 7 and 10.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, pelvis (72170) radiologic examination, ankle (73610) provided June 27, 2019.
You asked the Plan to pay for the radiology services. You say that please reprocess the claim for payment based on the extensions in place for COVID-19. The Plan denied your request. The Plan says the original claim was not submitted within 365 days from the date 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. The record shows that a claim for the radiology services was not filed until October 26, 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 for the radiologic examination, pelvis (72170) radiologic examination, ankle (73610) provided June 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for surgical debridement visits provided from October 1, 2020, to October 29, 2020.
You asked the Plan to waive the copayments for outpatient surgeries. You say that you feel these copayments are not correct and are too high for the procedures. The Plan denied your request. The Plan says the copayment 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 $150 copayment for each outpatient surgery visit to an outpatient hospital facility. There were 4 visits, resulting in a total copayment of $600. You have been asked to pay $150 copayment for each outpatient surgery. Outpatient surgeries fall within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for surgical debridement visits provided from October 1, 2020, to October 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have plantar fasciitis. The Plan denied your
request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.