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

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) and unspecified preventive procedure, by report (D1999) provided March 10, 2021.
You asked the Plan to pay for the pre-diagnostic test and unspecified preventative procedure. You say that the provider should have better discussed your dental situation earlier in the exam and you should not be responsible for the cost of the services provided. The Plan denied your request. The Plan says these services are not covered under your dental benefits.
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 adjunctive pre-diagnostic test (D0431) and unspecified preventive procedure, by report (D1999) provided March 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits (97164).
You asked the Plan to pre-approve the additional PT visits. You say that you are requesting this case be reviewed and the enrollee be provided an additional 20 visits at this time. The Plan denied your request. The Plan says the clinical documentation does not support the Medicare medical necessity criteria for the 10 additional physical therapy visits.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had prior therapy and the records do not demonstrate significant objective deficits on exam or that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part of a maintenance program, where the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. The enrollee should be able to transition to an independent home exercise program at this point. 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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits (97164).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair provided on November 11, 2020.
You asked the Plan to pay for a shower chair. You say that you are afraid of falling and breaking your hip or
leg. The Plan denied your request. The Plan says this item is not a covered benefit.
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 pay for a shower chair provided on November 11,
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says a review of the current medical literature indicates that this service 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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no compelling rationale presented or extenuating circumstances noted to support the medical
necessity of this request as an exception to guidelines. FDA contraindications include scoliosis, obesity, and
osteoporosis, and which have not been adequately addressed in the medical records. There is no documentation
of the enrollee's height, weight or body mass index. There is imaging evidence of scoliosis of the lumbar spine,
with no documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has
demonstrated the lack of significant osteoporosis in this enrollee. Therefore, the request for Vertiflex Superion
interspinous spacer at L4/5 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 the device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 2, 2020 and August 18, 2020.
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 they found that you have other insurance on file which was active from May 1, 2019 to September 30, 2020 and your dates of service are in between the effective and term date of your other insurance.
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. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has reached out to the other insurance to coordinate their benefits with no response. As the secondary insurer, the Plan cannot be held responsible for the laboratory services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 2, 2020 and August 18, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for medical supplies (A4207, A4670, E0485, E1399-NU) provided on October 2, 2020.
You asked the Plan to pay for medical supplies. You say that these items are supported in the records. The Plan denied your request. The Plan says that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while a patient.
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 stated that they denied these items because Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while a patient. However, when more information was requested, the Plan stated that there is no inpatient stay or services provided in relation to the items at issue in this appeal. The Plan has not provided further information supporting the denial of these items. Therefore, we decided that the Plan has to pay for medical supplies (A4207, A4670, E0485, E1399-NU) provided on October 2, 2020.
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 waive the copayment for lab services you had at an outpatient
hospital facility on March 23, 2021.
You asked the Plan to waive the copayment for the lab services. You say that the cost of lab services should be
covered in full. The Plan denied your request. The Plan says you were charged this copayment correctly. The
Plan says that because the allowed amount for these labs ($18.33) is less than your copayment obligation, you
are responsible for the full allowed 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 lab services at an outpatient hospital facility.
You have been asked to pay a $35 copayment for the lab services. 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 lab services you had at an outpatient hospital facility on March 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home infusion of Zinplava.
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 not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. The services are not covered under the Medicare Part B drug benefit. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. The Plan has approved the home infusion under the enrollee's Part D benefit. Therefore, we decided that the Plan does not have to pre-approve home infusion of Zinplava.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), comprehensive oral evaluation (D0150), and complete series of intraoral x-rays (D0210) provided on February 10, 2021, and February 17, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation, comprehensive oral evaluation, complete series of intraoral x-rays. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services exceed the frequency limitations in your benefit 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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on January 16, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. The Plan contract also includes comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210), and are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on February 3, 2020 and your comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), comprehensive oral evaluation (D0150), and complete series of intraoral x-rays (D0210) provided on February 10, 2021, and February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $35 copayment charge for urgent care services provided on March 26, 2021.
You asked the Plan to waive this copayment. You say that you fell and hit your head. You went to the urgent care facility and you were told they were unable to treat you and that you should go to the emergency room. You do not feel that you should have to pay the urgent care copayment. The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement.
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 $35 copayment for urgent care services. You chose to go to urgent care instead of the emergency room for treatment of a fall. The fact that they felt your evaluation should be done in an emergency room due to the possibility of head or spine injury does not negate the urgent care evaluation. It is the responsibility of the urgent care clinic to ensure enrollees receive the highest level of care possible depending on the clinical situation.
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 $35 copayment charge for urgent care services provided on March 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the extraction (D7140) provided on February 15, 2021 by an out of network provider.
You asked the Plan to pay the in network rate for the dental service. You say that you were instructed that your dentist was in network. You say that a plan representative advised the service would be covered at 100%. You also say that the service should be covered. The Plan denied your request. The Plan says there is a 50% coinsurance for extractions performed out of network. The Plan says that services performed out of network are paid based on the in network fee scheduled (INFS). The Plan says that you are responsible for the difference between the INFS and what the dentist charges. The Plan also says that a call was made to the plan to determine the network status of dentist other than the one in this case.
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, dental services performed out of
network may have a higher cost share amount. Out of network dentists may bill you for any amount greater
than what the plan pays. Additionally, records show that you received services from this dentist previously and
they were processed as out of network. Therefore, we decided that the Plan does not have to pay the in network
rate for the extraction (D7140) provided on February 15, 2021 by an out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on
February 17, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that this copayment should be
waived because it was related to the coronavirus. The Plan denied your request. The Plan says you were
charged this copayment correctly.
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 $250
copayment for ambulance services.
You have been asked to pay a $250 copayment for the ambulance services. There is no provision in your
contract stating that cost sharing for ambulance services is waived if related to the coronavirus. 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 ambulance services you received on February 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to provide coverage for SNF admission. You say that SNF admission is medically necessary for the enrollee.
The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services. The Maximus Physician Reviewer determined that the documentation supported that the requested SNF coverage is medically reasonable and necessary. The reviewer found that the enrollee required contact guard assistance to stand up and to walk 35 feet using a two wheeled walker. "The documentation does support that the enrollee has skilled therapy needs. The enrollee has not yet been shown to have reached a plateau in function. Daily skilled services are required to establish a maintenance program or to prevent deterioration of the enrollee's condition. Therefore, the enrollee does meet criteria for the requested services." The Plan requested a reopen and notes that at baseline the enrollee was using a walker but was declining. The enrollee was admitted to observation on March 11, 2021 which was changed to admission on March 12, 2021 because the enrollee could not be discharged to a SNF although she was ready for discharge. The Plan notes that the enrollee was experiencing a nonspecific functional decline independent of an acute illness. The medical records show the enrollee is a 94-year-old woman who presented to the hospital with vertigo, generalized weakness and joint pains. On March 11, 2021 it is documented that the enrollee had been "accepted to a rehab facility but unable to be transferred until tomorrow due to insurance concerns." On March 15, 2021 it is documented "Continue to wait for rehab authorization". The enrollee ambulated 25 feet with a front-wheeled walker. On March 16, 2021 the enrollee ambulated 35 feet with front-wheeled walker. Our Medical Director has concluded that the Plan is correct in this case. The documentation is insufficient to demonstrate that the enrollee required skilled therapy services on a "daily basis" in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that a bed will not be available, and you have already been in the hospital for 12 days. You say that you will not be able to live a happy and healthy life if the Plan doesn't approve the IRF care requested. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee's needs can be met at a less intensive level of care.
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 L2 compression fracture and had kyphoplasty. The enrollee's medical conditions 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. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral
complete series of radiographic images (D0210) provided on March 16, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, and an intraoral complete series of radiographic
images. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says
the services are a covered benefit, but you have exceeded the frequency limit of one every 3 years.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a comprehensive oral evaluation, and an intraoral complete series of radiographic images have not
been met. Specifically, the record shows that you had exceeded the frequency limit prior to these services on
December 6, 2019. Therefore, we decided that the Plan does not have to pay for a comprehensive oral
evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on March 16,