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

We decided that the Plan does not have to pre-approve a complete denture - mandibular lower arch.
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your
request. The Plan says this service is limited to once every sixty months.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dentures once
every sixty months/five years.
Dentures were last received less than five years ago on May 16, 2016. Based on this information, we decided
that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does
not have to pre-approve a complete denture - mandibular lower arch.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on January 24, 2020 by Lab and Radiology Services.You asked the Plan to pay forthis claim. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that this claim denied because the provider billed without the appropriate diagnosis code. The Plan says that the provider has billed this service as a routine serviceunder code 71046 or radiologicexaminationof the chest, two views, with diagnosiscodeZ01.818 to indicate an encounter for "other  pre-procedural  examination". The Plan states that routine preoperative chest x-rays are not appropriate.  The Maximus decisionstates the codesare not to be used in the examination is for diagnosis of suspected condition for treatment purposes. The Plan states that Medicare guidelines say in such cases the  diagnosiscode is required. The Planstates that pre-operative examination and pre-procedural laboratory examination Z codes are for use only in those situations when a patient is being cleared for a procedure or surgery and no treatment is given, according to the ICD-10-CM Official Guidelines for Coding and Reporting FY 2020. However, the code is being denied based on prepay rule 226-03. The Plan states that the diagnosis code Z01.818 is a nonspecific code. The Plan states that according to the American College of Radiology, a chest radiograph should not be performedforscreeningpurposes aspart of a routine physical, pre-admission,  or preoperative clearanceexamination in the absence of pertinent signs, symptoms or disease states. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. Review of the records provided, and the claim shows payment cannot be made due to the omissionof an appropriate diagnosis code. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on January 24, 2020 by Lab and Radiology Services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99204) needle electromyography
(95886) provided on July 31, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you were referred to this doctor by a participating
provider. Upon arrival you furnished your insurance card and was charged $40 copay. You can't afford these
payments and your credit is being ruined. The Plan denied your request. The Plan says enrollee's must receive
their medical services from an in-network provider with the exception being urgent or emergent services. Nonemergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for outpatient office visit (99204) needle
electromyography (95886) provided on July 31, 2020 by an out of network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on
September 24, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that neither talk you had
with the provider involved an emergency. The Plan denied your request. The Plan says benefits for this service
are limited to one time per calendar year.
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, emergency diagnostic exam is limited
to 1 every year. The record shows that you received a problem focused limited oral evaluation on June 18,
2020, and your emergency diagnostic exam benefit had been exhausted. Therefore, we decided that the Plan
does not have to pay for the problem focused limited oral evaluation provided on September 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the service dog support benefit.You asked the Plan to pre-approve the service dog support benefit. You say that you have diabetes and yourblood sugar level often drops below 60, especially at nights. You say that yourdog is a trained diabetes alert service dog that can alert you when yourblood sugar level drops below 70. You say that you believe that you have met all criteria and conditions ofthis benefit.The Plan denied your request. The Plan says that you have not supplied the required supporting documentation that identifies youas the owner of the service dog and that the service dog meets the American with Disabilities Act (ADA) service dog qualifications. The contract with the Plan says that the Plan requires supporting documentation identifying the enrollee as the owner and qualifying under the ADA for the service dog.We looked at the file and the Plan's rules. The file shows that there is not supporting documentation identifying youas the owner and qualifying under the ADA for the service dog.Therefore, we decided that the Plan does not have to pre-approve the service dog support benefit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Remicade 100mg vial for the enrollee.
You asked the Plan to pre-approve this is medically necessary.. You say that this is medically necessary. The Plan denied your request. The Plan says there has not been an adequate trial and failure of treatment with PUVA, UVB, methotrexate, cyclosporine, or acitretin.
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 this is medically necessary.. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the request for Remicade is not appropriate because the enrollee has not met the required medical necessity criteria. In particular, an adequate trial and failure of treatment with PUVA (ultraviolet radiation treatment (phototherapy) used for severe skin diseases), UVB (light therapy), methotrexate, cyclosporine, or acitretin. There is no documentation showing that shows that the enrollee has tried these treatments.
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 is medically necessary. have not been met. Therefore, we decided that the Plan does not have to pre-approve Remicade 100mg vial for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee may be appropriate for an alternate level of care, such as SNF.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted to
skilled nursing on 12/9/2020 after an acute stay for rhabdomylosis, hip fracture requiring surgical repair, and
COVID 19. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are
no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical
record documents a need for physical and occupational therapy, it does not document a need for an intensive
rehabilitation program. There is not a reasonable expectation that you 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that this is medically necessary.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fordiagnostic ultrasound procedures of the head and neck (76536) provided February 12, 2020.You asked the Plan to waive the copayment forthe diagnostic procedure. You say that you had paid $25 at the time of service because this classified as an x-ray. You were told that this shouldn't have been charged as an x-ray but rather as a lab test with a copay of $150.The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.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 $150 copayment for all other diagnostic tests.You have been asked to pay $150 copayment for the diagnostic procedure. The diagnostic procedure falls 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 copayment fordiagnostic ultrasound procedures of the head and neck (76536) provided February 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D2954).
You asked the Plan to pre-approve the services. You say that this is needed to complete your services for
crowns. The Plan denied your request. The Plan says this is not a covered 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, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
dental services (D2954).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you are in need of these supplies. The
Plan denied your request. The Plan says this is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal orthotic device (D7880).
You asked the Plan to pre-approve this device. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says this device is not a covered benefit under your dental
policy.
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 item is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal
orthotic device (D7880).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lactulose for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says this is intended for patient self-administration.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Lactulose for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 9, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing
rendered on July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe custom fabricated abutment and abutment supported porcelain/ceramic crown provided on August 19, 2020.You asked the Plan to pay forthe custom fabricated abutment and abutment supported crown. You say that in 2019 you were informed that your plan would pay $1,500.00 for crowns, but you waited until 2020 to have the services because you had already exhausted your 2019 benefits. You also say that you understood that you would be responsible for the costs of the dental implant procedure, excluding the costs of the crown.The Plan denied your request. The Plan says these services are not covered. The Plan says that although you have coverage for crowns, you do not have coverage for an abutment,or a crown used for a bridge.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. The records show that on August 12, 2019 you contacted the Plan to verify your benefits. The Plan says that you were emailed a list of providers and dental benefits, and accurate information was provided to you prior to the dental treatment.Therefore, we decided that the Plan does not have to pay forthe custom fabricated abutment and abutment supported porcelain/ceramic crown provided on August 19, 2020
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit provided on February 15, 2020.
You asked the Plan to pay for the services provided. You say that CPT code 99285 was down coded in error. The Plan denied your request. The Plan says the documentation did not support the code selection.
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 99285 is an emergency department visit with presenting problem(s) that are of high severity, and require urgent evaluation by the physician. We find that CPT code 99285 is not supported in the medical record. The documentation shows that the enrollee presented to the emergency room for the evaluation of anxiety. The records do not show that the enrollee's problems were of high severity. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit provided on February 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eye refraction provided on June 17, 2020.
You asked the Plan to reimburse you for eye refraction (92015). You say that the eye refraction should be
covered. The Plan denied your request. The Plan says the refraction was medical and therefore not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers an eye refraction when routine not medical.
We looked at the file and the Plan's rules. The provider has confirmed the eye refraction was medical. Based on
this information, we decided that the Plan's rules for coverage of eye refraction (92015) have not been met.
Therefore, we decided that the Plan does not have to reimburse you for eye refraction provided on June 17,
2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan does not have to provide coverage fora therapeutic continuous glucose monitor.You asked the Plan to provide coverage fora therapeutic continuous glucose monitor. You say that a therapeutic continuous glucose monitor ismedically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopenand stated that the Medicare coverage criteria are not met. The Plan says thatbased on the medical records provided, you have not been using a blood glucose monitor (BGM) and performing frequent (four or more times a day) testing, you are not insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-coveredcontinuous subcutaneous insulin infusion (CSII) pump and your insulin treatment regimen does not require frequent adjustment on the basis of BGM or CGM testing results. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees who meet all of the required criteria stated above. Based on the medical records provided, you do not meet all of the required criteria. While this device may be beneficial for your use, it is not covered by Medicare if you do not meet all of the required criteria. Therefore, we decided that the Plan does not have to provide coverage fora therapeutic continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested lumbar laminectomy, facetectomy and
foraminotomy.
You asked the Plan to pre-approve the requested lumbar laminectomy, facetectomy and foraminotomy. You
say that the requested lumbar laminectomy, facetectomy and foraminotomy is medically necessary. The Plan
denied your request. The Plan says the requested lumbar laminectomy, facetectomy and foraminotomy 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 the requested lumbar laminectomy,
facetectomy and foraminotomy. Our reviewer says that the requested lumbar laminectomy, facetectomy and
foraminotomy is not medically necessary. Our physician reviewer found the enrollee is with lumbar stenosis.
The imaging studies do not show any evidence of severe spinal stenosis or instability. Additional spine surgery
is not medically needed. Criteria for surgery have not been 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 the requested lumbar laminectomy, facetectomy and foraminotomy have not
been met. Therefore, we decided that the Plan does not have to pre-approve the requested lumbar laminectomy,
facetectomy and foraminotomy.