Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea maxillary partial denture (D5213).You asked the Plan to pre-approvethe maxillary partial denture. You say that your previous partial had wires that attach to teeth that you no longer have. You also say that you need a new partial in order to eat.The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.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 thiscase.Though the Plan offers a dental benefit in excess of Medicare coverage, maxillary partial dentures are limited to one procedure every five plan years. The record shows that you received a maxillary partial denture (D5211) on January 26, 2018, and your maxillary partial denture benefit has been exhausted.Therefore, we decided that the Plan does not have to pre-approvea maxillary partial denture (D5213)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical assistant services provided on December 6, 2019 billed with code 27487-AS.
You asked the Plan to pay for the surgical assistant services. You say that it is felt that this should be paid. The Plan denied your request. The Plan says there is no evidence of involvement of the femoral component as required by the billed code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 27487 is Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component. We asked our coding 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 surgical assistant services. Our reviewer says that the documentation does not support the billing of this code. Our coding reviewer found the operative report documents "The patellar and femoral components were well fixed. The tibial component was loose. I removed the tibial component and took fluid and culture samples, which were sent to the lab". Documentation does not support procedure performed on femoral component; therefore, this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical assistant services provided on December 6, 2019 billed with code 27487-AS.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from December 28, 2019 to December 30, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that this claim should be paid. The Plan denied your request. The Plan says that inpatient coverage criteria were not met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found this is a case of an elderly male who presented with acute onset of several episodes of syncope within a few days. There was no known cause of his syncope at the time of his presentation and therefore thorough workup would be medically necessary in order to undercover the diagnosis. It is reasonable to expect that his length of hospitalization would span 2 midnights upon his presentation to the ER. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from December 28, 2019 to December 30, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room services provided on March 27, 2020.
You asked the Plan to waive the copayment for the emergency room services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received emergency care services on the date of service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan.
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 $90 copayment for Emergency care. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room services on March 27, 2020. You have been asked to pay a $90 copayment for the emergency room services. The emergency room services fall within the Emergency care 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 the emergency room services provided on March 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean additional iStent insertion coded as 0376T.You asked the Plan to pre-approvethe additional iStent. You say that this should be approved in full.The Plan denied your request. The Plan says Medicare only allows coverage for one iStent placement. Additional placements are included in the reimbursement of the first.The Plan must follow Medicare rules. Medicare rules say that additional insertions of iStent devices are not considered medically reasonable and necessary. Only one iStent insertion may be covered.Therefore, we decided that the Plan does not have to pre-approvean additional iStent insertion coded as 0376T.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe Part B prescription drugs and outpatient surgery provided from June 1, 2020 to June 29, 2020.You asked the Plan to waive the cost share forthe Part B prescription drugs and outpatient surgery. You say that you would like the Plan to reconsider your request.The Plan denied your request. The Plan says the Plan processes claims and adjustments in accordance with how they are received. The Plan assessed cost share according to the Plan benefits. The Plan cannot change which claim your cost share was applied to. The Plan has overturned the cost applied to service 96372 (x5). The total of $364.00 ($72.80 x 5) has been waived by the Plan. The Plan says that because they are waiving the cost share, you willno longer have reached your out-of-pocket maximum and any future claims received are subject to the applicable cost share up to the remaining out-of-pocket amount of $364.00.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 20% coinsurance for Medicare Part B prescription drugs and a $95 copayment for outpatient surgery. We looked at the file, the Plan's contract and Medicare rules. The Plan processes claims and adjustments in accordance with how they are received. The Plan assessed cost share according to the Plan benefits. The Plan cannot change which claim your cost share was applied to. The Plan has overturned the cost applied to service 96372 (x5). The total of $364.00 ($72.80 x 5) has been waived by the Plan. The Plan says that because they are waiving thecost share, you will no longer have reached your out-of-pocket maximum and any future claims received are subject to the applicable cost share up to the remaining out-of-pocket amount of $364.00.Therefore, we decided that the Plan does not have to waive the cost share forthe Part B prescription drugs and outpatient surgery provided from June 1, 2020 to June 29, 2020
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to waive the charges for the drugs billed under code A9270 provided during an emergency room visit.

You asked the Plan to waive the charges for the drugs. You say that all drugs you were given were given by the hospital staff.The Plan denied your request. The Plan says that this self-administered drug is not covered by Medicare Part B.

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 file does not include an itemized bill that identifies the drug/drugs that were given during this visit. As such, Maximus cannot verify that the drug in question is indeed a drug that is usually self-administered. It is not that the patient liability is zero for this claim, but no invoice was provided. As such, it cannot be verified whether the zero balance is due to patient payments on the account. Without this information, we find that the denial of payment at issue is not supported.Therefore, we decided that the Plan has to waive the charges for the drugs billed under code A9270 provided during an emergency room visit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Serostim.
You asked the Plan to pre-approve Serostim (J2941). You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says this drug 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 Serostim.
Benefits for Serostim (J2941) 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power wheelchair power seat elevation feature.You asked the Plan to pre-approvea power seat elevation feature (E2300). You say that a seat elevator is medically necessary because of your medical condition.The Plan denied your request. The Plan says a seat elevator is not primarily medical in nature.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This feature is not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approvea power wheelchair power seat elevation feature.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is with spinal stenosis. The device is experimental. More research is needed to show safety and efficacy. There is no spinal instability documented. Therefore a stabilization device is not needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Respiratory infectious agent detection test,code 87631, provided.

You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria were not met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the services provided are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for Respiratory infectious agent detection test, code 87631, provided to the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe x-ray services coded 71045 provided on May 6, 2020.You asked the Plan to pay forthe x-ray services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are missing required information.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 71045 is not supported in the medical record. Specifically, the enrollee was inpatient at a skilled nursing facility during this date of service. If the enrollee is an inpatient at a covered Part A SNF stay, the provider may only bill and be paid on the physician's professional services. Therefore, this service is not separately payable. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met.Therefore, we decided that the Plan does not have to pay forthe x-ray services coded 71045 provided on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGrafix Prime and Grafix Core.You asked the Plan to pre-approveGrafixPrime and Grafix Core. You say that the clinical information provided supports the medical necessity of the requested services.The Plan denied your request. The Plan says bio-engineered tissue products for wound treatment and surgical interventions are considered medically necessary for diabetic foot ulcers only.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 Grafix Prime and Grafix Core. Our reviewer says that Grafix Prime and Grafix Core are not considered medically reasonable and necessary in this case. Our physician reviewer found Grafix Core is an allograft containing endogenous mesenchymal stem cells indicated for the treatment of deep chronic wounds, limb salvage procedures, tendon repair and burns. Grafix Prime is an allograft containing endogenous mesenchymal stem cells indicated for upper epithelial layer chronic wounds and burns.The enrollee does not have documentation of a chronic wound, and there is no documentation of failed conservative wound management. There is not strong evidence that Grafix Core and Grafix Prime impact the outcomes of such wounds.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Grafix Prime and Grafix Core have not been met.Therefore, we decided that the Plan does not have to pre-approveGrafix Prime and Grafix Core.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for[complete description of item or service at issue, e.g. at issue is "a power wheelchair provided by The Wheelchair Store on January 12, 2016."]You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plandenied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items orderedand for the frequency of use. 
The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have topay for[complete description of item or service at issue, e.g. at issue is "a power wheelchair provided by The Wheelchair Store on January 12, 2016."]
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation for diagnostic dental services (D9310) provided.

You asked the Plan to pay for the consultation for diagnostic dental services. You say that you thought this service would be covered since you pay extra for a dental rider.The Plan denied your request. The Plan says the service provided is not a covered benefit under your dental 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 the consultation for diagnostic dental services (D9310) provided.
Appeal type: Drugs
Decision: Favorable

We decided that the Planhasto pre-approveProlia 60mg/ml syringe for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthatstep therapy guidelines were not followed.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 the drug. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found per the prior authorization form, the enrollee has osteoporosis. It appears that the enrollee has already been taking Prolia to treat this condition and that a reauthorization has been requested. The health plan has not argued that the medication is not medically necessary and, in fact, has approved the drug under the enrollee's part D benefit.  Instead, the health plan is arguing that step therapy criteria have not been met.  Step therapy criteria may not be applied to a medication that is already being taken by an 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 the drug have been met.Therefore, we decided that the Planhas to pre-approveProlia 60mg/ml syringe for the enrollee.
If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement forthe power seat elevation system described by code E2300 purchased on June 30, 2020.You asked the Plan to provide reimbursement forthe power seat elevation system. You say that you do not understand why this feature is being denied when it is clearly necessary for the enrollee. He requires this in order to get into a standing position. This is not a convenience feature and should be covered.The Plan denied your request. The Plan says this is not an item that is covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that DME is defined as equipment that is used for a primarily medical purpose. Wheelchair options/features are covered when they meet the definition of DME. The rules say that a power seat elevation feature is not primarily medical in nature.Although this feature may be appropriate for the enrollee and may be needed for his care, it does not meet the definition of DME according to Medicare rules. Neither Medicare nor the Plan is allowed to make payment for this feature.Therefore, we decided that the Plan does not have to provide reimbursement forthe power seat elevation system described by code E2300 purchased on June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transports.

You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says you have exhausted the benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve additional routine transports
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on March 3, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says these services are not covered for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered. This service was 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 pay for lab
services provided to the enrollee on March 3, 2020.