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

We decided that the Plan does not have to pay for lab services provided to the enrollee.

You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of testing. 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 this claim. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found based on the documentation provided the enrollee was seen for routine follow-up of chronic conditions. There is no evidence of signs or symptoms related to GU/UTI problems. While the acquisition of a urine dip and/or urinalysis in a diabetic may have been reasonable (monitoring for glucose, protein, UTI), the acquisition of the molecular UTI test was not medically necessary or reasonable. NCD coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services received on September 28, 2019.
You asked the Plan to pay for the services. You say that there was no payment on this claim. The Plan denied your request. The Plan says this was not filed in a timely manner.
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 services was not filed until October 7, 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 diagnostic radiology services received on September 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 10, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you feel that the service rendered should not warrant a copayment. 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 $35 copayment for each specialist visit. The medical records show that you had a specialist visit on December 10, 2020. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 copayment for a specialist visit. A specialist 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 copayment for a specialist visit provided on December 10, 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).
You asked the Plan to pre-approve Synvisc. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried conservative treatment.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Synvisc. Our reviewer says that the criteria for coverage of Synvisc have not been met. Our physician reviewer found there is no radiology report showing severe knee medial or lateral compartment arthritis. There is also not sufficient documentation of conservative measures for knee pain including a failure of 2 types of oral medication, knee steroid injections, and a recent 6-week trial of physical therapy for knee pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0220, D2393) provided to the enrollee on November 2, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the service provided is not a covered benefit under 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 pay for dental services (D0220, D2393) provided to the enrollee on November 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network surgeon.
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 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. 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 surgeon.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Rituxan (J9312).
You asked the Plan to pre-approve Rituxan. You say that the item is medically necessary. The Plan denied your request. The Plan says that the item is investigational.
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 medical records for this member have not been submitted. Therefore, we decided that the Plan has to pre-approve Rituxan (J9312).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to further reimburse you for the prosthetic eye (V2623) purchased from an 
out-of-network (OON) provider.

You asked the Plan to further reimburse you for the prosthetic eye. You say that you would like to be further reimbursed for the services you received. The Plan denied your request. The Plan says the reimbursement processed according to the Medicare Fee Schedule and no further reimbursement is due.

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 0% coinsurance in-network and a 20% coinsurance out-of-network for durable medical equipment.

In this case, the Plan has reimbursed you the complete Medicare allowed amount of $737.06. The remaining cost of $1062.94 is the difference between what the provider charged you ($1800) and the Medicare allowed amount. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to further reimburse you for the prosthetic eye (V2623) purchased from an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays, prefabricated post and core in addition to crown, and endodontic therapy provided on September 25, 2020, and October 6, 2020.
You asked the Plan to pay for the complete series of intraoral x-rays, prefabricated post and core, and endodontic therapy. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered. The Plan also say that you were advised of what services your plan covers during a call on September 2, 2020.
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 complete series of intraoral x-rays, prefabricated post and core in addition to crown, and endodontic therapy provided on September 25, 2020, and October 6, 2020.
Your complaint about being upset with the services and your coverage is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider at the in-network rate.
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 available from network providers at the in-network rate.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 35% coinsurance for each Medicare-covered outpatient surgery at an out-of-network hospital outpatient facility.
The requested facility is not a network provider with the Plan. If the enrollee chooses to receive services from this facility, they will be asked to pay a 35% coinsurance for these services. These services fall within the Medicare-covered outpatient surgery at an out-of-network hospital outpatient facility benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider at the in-network rate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft and free soft tissue graft procedure provided on February 11, 2020.
You asked the Plan to pay for the bone replacement graft and free soft tissue graft procedure. You say that you feel that these services should be covered. The Plan denied your request. The Plan says these services 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. Therefore, we decided that the Plan does not have to pay for the bone replacement graft and free soft tissue graft procedure provided on February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray, preventive procedure, comprehensive oral evaluation, and prophylaxis provided on October 29, 2020 by an OON provider.
You asked the Plan to pay for the panoramic x-ray, preventive procedure, comprehensive oral evaluation, and prophylaxis. You say that you believe these services should be covered by the Plan. The Plan denied your request. The Plan says the panoramic x-ray and preventive procedure are not covered benefits. The Plan also says that the comprehensive oral evaluation and prophylaxis were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.
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 panoramic x-ray and unspecified preventive procedure are not among those covered under this benefit. The contract clearly states that you must pay a 50% coinsurance for both comprehensive oral evaluations and prophylaxes when the services are received OON. The Plan contract also says that you are responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray, preventive procedure, comprehensive oral evaluation, and prophylaxis provided on October 29, 2020 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tacrolimus.
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 self-administered drugs are not covered.
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 tacrolimus.
Benefits for these services 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says Prolia (J0897) is approved on the enrollee's Part D benefit for March 16, 2021, to December 31, 2021.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Benefits for Prolia 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation (92004) rendered by the out of network (OON) provider on December 3, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation (92004) rendered by the out of network (OON) provider on December 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance (eg, proton) imaging (MRI) of the brain (70553) to be obtained by an out-of-network provider.

You asked the Plan to pre-approve a MRI of the brain. You say that the service is medically necessary. The Plan denied your request. The Plan says services can be obtained through an in-network provider.

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 a magnetic resonance (eg, proton) imaging (MRI) of the brain (70553) to be obtained by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha sureclick.
You asked the Plan to pre-approve Repatha sureclick. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Repatha sureclick is not covered under the enrollee's Medicare Part B 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 Repatha sureclick.
Benefits for Repatha sureclick 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Simponi Aria.
You asked the Plan to pre-approve Simponi Aria. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the diagnosis listed is not a covered indication for this drug.
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 Simponi Aria. Our reviewer says that based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that Simponi Aria is FDA-approved for the enrollee's diagnosis. There is no documentation that this use is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found there is no documentation that Simponi Aria for undifferentiated inflammatory arthritis is safe and effective and otherwise reasonable and necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not have to pre-approve Simponi Aria.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis (L3960).

You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis. You say that the requested orthosis was medically necessary for the enrollee. The Plan denied your request. The Plan says there is no evidence that the prescribing physician ever saw the member.

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 shoulder-elbow-wrist-hand orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a physical examination of the shoulder would reasonably be required to adequately assess whether the orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the shoulder. 

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 shoulder-elbow-wrist-hand orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis (L3960).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation provided on January 13, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for the ambulance transportation provided on January 13, 2020.