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

We decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says the requested injection is 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 block. Our reviewer says that the requested block is not considered medically reasonable and necessary in this case. Our physician reviewer found the effective of this injection to treat knee pain has not been established. Genicular nerve blocks are considered experimental and investigational in nature. As such, bilateral genicular nerve blocks are not reasonable and medically 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 block have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis - adult (D1110) provided from October 8, 2019 
through December 5, 2019. 
 
You asked the Plan to pay for the dental services. You say that you would like the cleanings to be covered 
because they had been in the past. You state you did not realize that cleanings and periodontal maintenance fell 
under the same category in terms of frequency limitations. The Plan denied your request. The Plan says you 
exhausted your benefit frequency limit. 
 
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. 
 
You exhausted your benefit frequency limit, because you periodontal maintenance performed on January 21, 
2019 and May 23, 2019 and a cleaning performed on July 31, 2019. Your EOC states, the Plan covers routine 
cleaning of teeth and/or periodontal (gum) maintenance up to three (3) times per calendar year. Therefore, we 
decided that the Plan does not have to pay for prophylaxis - adult (D1110) provided from October 8, 2019 
through December 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing based on medical 
necessity. The Plan denied your request. The Plan says the denial of authorization for LTACH service is 
correct. 
 
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 the short-term acute care hospital can provide for all the enrollee's present inpatient 
care needs and the enrollee is receiving an appropriate level of care in the current setting. Continued care in the 
current short-term acute care hospital is appropriate until the enrollee is able to transfer to a lower level of care 
such as an inpatient rehabilitation facility, sub-acute rehabilitation facility, or skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that you do not like the care at your previous facility. The Plan denied your request. The Plan says the services are available from network providers.
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. The Plan confirmed they have tertiary level providers available that are equipped to provide the same level of care as the requested provider. 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 a referral to an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond August 4, 
2020. 
 
You asked the Plan to pre-approve the continued inpatient care. You say that the enrollee needs continued 
inpatient care in order to titrate medications before discharge. The Plan denied your request. The Plan says the 
enrollee does not require continued inpatient care to allow for the necessary services. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient care. Our 
reviewer says that the requested continuation of inpatient psychiatric care is not considered medically 
reasonable and necessary. Our physician reviewer found this 70-year-old female was involuntarily admitted to 
the acute inpatient psychiatric hospitalization on July 27, 2020 with psychosis. Based upon review the records 
provided, it was not expected this enrollee would improve in a reasonable period of time for the dates in 
question as she did not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. The 
patient has some delusions but she is less adamant about those feelings at this time. It did not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care beyond the dates in question as she did not have dangerousness to self or others but was 
compliant with her treatment. The health plan's denial of continued inpatient psychiatric services is appropriate. 
It did not appear that the services were reasonably expected to improve the patient's condition or for the 
purpose of diagnosis beyond the date in question. 
 
 
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 continued inpatient care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued inpatient psychiatric care beyond August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental extraction to be done by an oral surgeon.
You asked the Plan to pre-approve the extraction. You say that this is medically necessary. The Plan denied your request. The Plan says dental services are only covered when rendered by a participating general dentist - dental services 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. The Plan covers dental services when provided by a participating general dentist. The services are to be provided by a non-covered provider type - oral surgeon. Based on this information, we decided that the Plan's rules for coverage of the extraction have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental extraction to be done by an oral surgeon.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 20, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for laboratory tests. You say that you are a participating provider with the Plan. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because this 
provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan. 
 
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 has network providers 
available who can provide 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 the medical services provided on December 20, 
2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are very unsteady on your feet and bathing 
is extremely unsafe for you. The Plan denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of the implant body (D6010) provided 
December 5, 2019. 
 
You asked the Plan to pay for the dental services. You say that you feel that the services should be covered 
because the dentist had followed proper protocol and the preauthorization was approved and you were told that 
the procedures would be covered. The Plan denied your request. The Plan says the provider was paid more by 
the primary insurer than what Medicare allows or would have paid for the same services had the Plan been the 
primary payer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. The provider billed $1,833 for the 
services. The primary insurance paid $1,336.00 which is 80% of the billed amount of the claim. The plan has 
confirmed that the payment made by the primary insurance company was more than what would have been 
paid by Medicare. As the secondary insurer, the Plan cannot be held responsible for the dental services as no 
further reimbursement is available under the Medicare payment guidelines. Therefore, we decided that the Plan 
does not have to pay for surgical placement of the implant body (D6010) provided December 5, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 99285 provided on March 3, 2020. 
 
You asked the Plan to pay for CPT code 99285. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. The file shows that the Plan has paid for CPT code 99285 provided 
on March 3, 2020. There is no documentation available in the case file showing that more than one unit of CPT 
code 99285 was provided to the enrollee on March 3, 2020. Therefore, we decided that the Plan does not have 
to pay for CPT code 99285 provided on March 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Azithromycin 250mg tablets.
You asked the Plan to pre-approve Azithromycin. You say that this drug is medically necessary. The Plan denied your request. The Plan says Azithromycin is not eligible for coverage under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Azithromycin 250mg tablets.
Benefits for Azithromycin may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight additional days of inpatient mental health care 
from June 28, 2020. 
 
You asked the Plan to pre-approve the inpatient care. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient care. Our reviewer says 
that the requested inpatient mental health care is not medically reasonable and necessary. Our physician 
reviewer found that it was not expected this enrollee would improve in a reasonable period of time for the dates 
in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual 
hallucinations. The patient was compliant with treatment while not showing any acute threats to safety. It did 
not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of 
care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or 
others but was compliant with her treatment. The admission of this patient does not meet the criteria for 
continued acute inpatient mental health treatment for the dates in question of June 28, 2020 forward as this 
patient was not shown to be a danger to herself or others. She was not showing any auditory or visual 
hallucinations and was cooperative/compliant with treatment while not showing any acute threats the safety. 
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve eight additional days of inpatient mental health care from June 28, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the out-of-network office visit (99215) and duplex scan (93970). 
 
You asked the Plan to pre-approve the office visit and duplex scan. You say that you would like 
reconsideration because you have a contract with the facility to see nursing home patients at their bedside. The 
Plan denied your request. The Plan says that the member does not have a benefit for out-of-network coverage 
unless the services are urgent or cannot be provided in-network. 
 
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 clarified if the member is in a custodial stay, if the preferred in-
network providers are able to render this service in the facility or if the enrollee should be required to leave the 
facility in order to receive these services. Therefore, we decided that the Plan has to pre-approve the out-of-
network office visit (99215) and duplex scan (93970).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided 
on January 25, 2020. 
 
You asked the Plan to pay for the CGP testing. 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. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the CGP testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the Comprehensive Genomic Profile (CGP) testing provided on January 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 26, 2019. 
 
You asked the Plan to pay for the laboratory services. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on August 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron for the
enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Part B drug injections provided on March 6, 2020.
You asked the Plan to waive the copayment for the Part B injections. You say that this injection should be covered in full as a part of your surgery. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 10% of the total cost up a $100 quarterly maximum for in-network Medicare Part B chemotherapy drugs, associated administration services and all other Medicare Part B drugs. You have been asked to pay $100 for the Part B injections. The Part B injections fall within the "Medicare Part B prescription drugs" benefit category. The record shows you received this injection at an outpatient hospital. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
March 6, 2020
Part B injection
$964.61
10%
$96.46
March 6, 2020
Part B injection
$964.61
10%
$3.54 - This is less than the 10% coinsurance amount.
Total
$100.00
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 Part B drug injections provided on March 6, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an observation stay provided from March 
21, 2020 to March 24, 2020. 
 
You asked the Plan to waive the copayment for an observation stay. You say that you disagree with the charges 
because you presented with the same symptoms as a previous stay. 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). Your contract with the Plan clearly says that you must pay a $200 
copayment for outpatient hospital observation.  
 
You have been asked to pay a $200 copayment for an observation stay. An observation stay falls within the 
outpatient hospital observation 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 observation stay provided from March 21, 2020 to March 24, 2020.  
 
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit 
MAXIMUS to make a decision on this type of complaint.