Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this would benefit you. The Plan denied your request. The Plan says information is needed as to what daily activities are not able to be safely completed without the requested wheelchair.
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 wheelchair. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you do not have severe spasticity. The documentation does not reveal that your mobility limitation cannot be sufficiently resolved using an appropriately fitted walker. The request for this heavy-duty wheelchair is not 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair with multiple power options (K0842).
You asked the Plan to pre-approve the group 2 power wheelchair. You say that a new power chair is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 group 2 power wheelchair. Our reviewer says that the requested power chair is not medically necessary. Our physician reviewer found the mobility and seating evaluation does not state if the enrollee's condition can be helped by a manual wheelchair. The physician notes state the enrollee is blind. The documentation by the physician does not support that the enrollee can safely operate a PMD. 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 group 2 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair with multiple power options (K0842).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a calf pad cover and a replacement cover for the wheelchair cushion for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this should be reconsidered based on medical necessity. The Plan denied your request. The Plan says these are convenience items and do not primarily serve a medical purpose.
The Plan must follow Medicare rules. Medicare rules say that for equipment to be covered, it must serve a primarily medical purpose. 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 accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items are convenience items, and are not needed for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a calf pad cover and a replacement cover for the wheelchair cushion for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided on January 14, 2020 to
March 31, 2020 by an out of network provider.
You asked the Plan to pay for the services provided. You say that the provider is in-network. The Plan denied
your request. The Plan says the provider is not a certified provider available for you to utilize.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that you receive care from a provider who is eligible to provide services under Original Medicare.
The requested provider in this case is not a network provider with the Plan. The documentation provided does
not show that the provider at issue is eligible to provide services under Original Medicare. The Plan did not
pre-approve the service at issue. We found no exception that would require the Plan to pay for these services.
Therefore, we decided that the Plan does not have to pay for the home health services provided on January 14,
2020 to March 31, 2020 by an out of network provider.
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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you required total assistance with bed rolling. You required maximum assistance times two to sit up. You required total assistance times two to lie down. You required maximum assistance to sit down. The documentation does not support that you require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on July 9, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation does not support a valid order for these tests.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on July 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation provided on January 27, 2020 by an OON
provider
You asked the Plan to pay for the consultation. You say that the dentist you see should be in-network. The Plan
denied your request. The Plan says this service was received by an OON provider. The Plan also says that the
Plan requires services to be performed by a contracted dentist.
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
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the
consultation provided on January 27, 2020 by an OON provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on February 26, 2020, by an OON provider.
You asked the Plan to pay for the prophylaxis. You say that you have sent a few claims in to the Plan, but 2 of the claims were not paid to the full amount, and other claims have been lost. The Plan denied your request. The Plan says this service was performed by an OON provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a 50% coinsurance for dental services rendered by an out-of-network provider. The contract also clearly states that you may be billed by the OON provider for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on February 26, 2020, by an OON provider.
Your complaint about your issues with the Plan 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0481) provided to the enrollee on October 7, 2019.
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 documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
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 HCPCS code G0481 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found Medicare rules state that if a lab bills laboratory services to Medicare, there must be a signed order from the treating physician (or a progress note to support the intent to order) and documentation to support the medical necessity of the ordered services. In this case, the case file contains only a Custom Toxicology Profile order forms, and the results of the testing. There are no medical records in the case file. There is no evidence that the UDT was tailored to the enrollee's medical condition. There is no documentation supporting an established relationship between the ordering physician and the enrollee. Therefore, the documentation does not support that the UDT was medically reasonable and necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0481) provided to the enrollee on October 7, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan does not have to waive the $275 copayment charged for ambulance transport
provided on November 15, 2019.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The
Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement.
Maximus overturned the Plans denial because the 2019 Plan contract was not submitted for review. The Plan
requested a reopen and provided the 2019 Plan contract.
The Plan is correct in this case. 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 2019 Plan contract states
there is a $275 copayment for ambulance transport. 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 $275 copayment charged for
ambulance transport provided on November 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 28, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on February 6, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you believed you plan would not have any copayments. You say you cannot afford the copayment. 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 a $65 copayment per visit for Medicare-covered urgently needed services. You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" 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 urgent care visit provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on January 7, 2020.
You asked the Plan to pay for 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 modifier -26 cannot be used with codes with a PC/TC indicator of 0. We looked at the file and Medicare rules. The provider submitted a claim for procedure code 99214 with modifier -26. This code has a PC/TC indicator of 0 and cannot be billed with the -26 modifier. Therefore, we decided that the Plan does not have to pay for the office visit rendered on January 7, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for X-rays and to waive the coinsurance for 
vascular diagnostic services provided on November 15, 2019. 
 
You asked the Plan to waive the copayments for X-rays and to waive the coinsurance for vascular diagnostic 
services. You say that you disagree with the charges because you already paid the $45 copayment and have 
never been charged for multiple services in the past. 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 $14 
copayment for X-ray services and 20% coinsurance for radiological diagnostic services. 
 
The medical records show that you received multiple X-rays on November 15, 2019. Therefore, you are 
responsible to pay the total copayment amount of $28.  
 
The medical records show that you received vascular diagnostic services on November 15, 2019. The allowed 
amount is $85.45 and 20% of that is $17.09.  
 
The total amount you owe is: $45.09 
 
You have been asked to pay the total amount of $45.09 for X-rays and vascular diagnostic services. X-rays and 
vascular diagnostic services fall within the outpatient diagnostic tests and therapeutic services and supplies 
benefit category. 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for X-rays and to waive the coinsurance for vascular 
diagnostic services provided on November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection. 
 
You asked the Plan to pre-approve a lumbar epidural steroid injection. The Plan denied your request. The Plan 
says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that lumbar epidural steroid injections are covered when 
the above criteria are met. 
 
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 lumbar epidural steroid injection. Our 
reviewer says that the requested lumbar epidural steroid injection is not medically reasonable and necessary. 
Our physician reviewer found that there is no documentation indicating that the enrollee has radiculopathy. The 
requested injection is not medically reasonable or necessary according to the coverage criteria established in 
the above LCD. 
 
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 lumbar epidural steroid injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lumbar epidural steroid injection.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a temporomandibular splint to treat a temporomandibular joint 
(TMJ) pain. 
 
You asked the Plan to pre-approve a temporomandibular splint. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says that the requested item is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically 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 a temporomandibular splint. Our 
reviewer says that the documentation supports that the requested splint is medically reasonable and necessary. 
Our physician reviewer found the enrollee has a diagnosis of intermittent TMJ disc displacement causing the 
enrollee pain. Conservative treatment of anti-inflammatory medications was ineffective. The use of splint 
therapy is the standard of care for treatment of this condition. The documentation indicates that the most 
conservative treatment for this patient was ineffective. Therefore, the enrollee meets criteria for the requested 
TMJ splint. 
 
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 temporomandibular splint have been met. Therefore, we decided that the Plan 
has to pre-approve a temporomandibular splint to treat a temporomandibular joint (TMJ) pain.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on July 24, 2019. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you did not have an option to 
get transported by your family. You say that you do not feel like this is right. The Plan denied your request. 
The Plan says the correct copayment has been applied. 
 
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 $125 
copayment for ambulance services.  
 
You have been asked to pay a $125 copayment for an ambulance trip. Since ambulance services were provided, 
the correct copayment has been applied. An ambulance trip falls within the ambulance services 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 ambulance trip provided by a participating 
provider on July 24, 2019.