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

We decided that the Plan does not have to pay for the pontic provided on January 8, 2020.
You asked the Plan to pay for the pontic. You say that you should not be charged any more than the allowed amount of $484.94 that is shown on your explanation of benefits. The Plan denied your request. The Plan says the maximum benefit amount available for 2020 has been paid.
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 Plan offers a $500 annual dental benefit maximum. The record shows that you met the annual maximum benefit on January 8, 2020 and your annual maximum benefit has been exhausted. The record shows that the Plan confirmed with the provider that you were advised you would be charged for the full amount because you would meet your out-of-pocket maximum of $500. Therefore, we decided that the Plan does not have to pay for the pontic provided on January 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on September 27, 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 procedure codes 95913 and 95886 are not supported.
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 95913 is nerve conduction studies; 13 or more studies. The definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). We find that CPT codes 95913 and 95886 are not supported in the medical record. Specifically, there is no documentation of 13 or more studies performed to support code 95913. Given that the primary code 95913 is not supported, the add-on code 95886 is also not supported. 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 testing services rendered on September 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 23, 2019 by an out of network (OON) provider.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 were rendered by an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The 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 the medical services provided on October 23, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zarxio. You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee was recently diagnosed with primary non-small cell lung cancer. 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 the drug. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found Zarxio is standard to decrease the incidence of infection (neutropenic fever) in patients with nonmyeloid malignancies receiving myelosuppressive chemotherapy associated with a significant incidence of severe neutropenia with fever. This patient is being treated for curative intent and has a low ANC not allowing chemotherapy to be given on time. The use of a growth factory such as Zarxio is standard to allow chemotherapy to be given for curative intent. The service is reasonable and 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 drug have been met. Therefore, we decided that the Plan has to pre-approve Zarxio.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed.
You asked the Plan to pre-approve the requested bed. The Plan denied your request. The Plan says the notes do not show that the enrollee weighs at least 350 pounds.
The Plan must follow Medicare rules. Medicare rules say that hospital beds are only covered under certain medical indications.
We looked at the file and Medicare rules. The documentation provided does not show that the enrollee's weight meets the guidelines for coverage. 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 pre-approve a heavy duty extra wide hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for intraoral-complete series x-rays (D0210) provided February 14, 2020.You asked the Plan to waive the copayment for the dental services. You say that you went to an out of network dentist and now have a $25 copay. You do not see a $25 copay indicated anywhere in the optional supplemental services in the EOC.The Plan denied your request. The Plan says this claim was processed correctly and 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 $25 copayment for covered preventive and diagnostic dental services. You can get care from an out-of-network dental provider but you may pay more. You have been asked to pay $25 copayment for the dental services. The services fall within the Dental 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 intraoral-complete series x-rays (D0210)provided February 14, 2020.
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 a LTACH admission is medically
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for
coverage of a LTACH admission.
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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH)
for shortness of breath. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires
services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care,
there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH
until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level
of care for any ongoing long term care needs.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral exam (D0140) provided February 20, 2020.
You asked the Plan to pay for the dental services. You say that your regular dentist referred you to this provider to treat a pocket of infection/pus eating away at the bone. She did fine work and should be paid. The Plan denied your request. The Plan says this service exceeds the frequency limitation.
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. This service is allowed once per year. The records show this same service was provided February 3, 2020. 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 limited oral exam (D0140) provided February 20, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia.
You asked the Plan to pre-approve Orencia. The Plan denied your request. The Plan says the enrollee has not had prior therapy, contraindication, or intolerance to Simponi Aria.
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 Orencia. Our physician reviewer found that the enrollee has rheumatoid arthritis. Based on the records provided, she has tried Remicade, Rinvoq, Enbrel, and Humira, but is still having active disease symptoms. The Plan requires a trial of drug Simponi Aria first before they will approve the requested drug. The provided medical records do not indicate that the enrollee has tried and failed the required drug. The provided medical records do not indicate that the Plan's required drug would likely be less effective, or likely have adverse effects for the 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 Orencia have not been met. Therefore, we decided that the Plan does not have to pre-approve Orencia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on January 29, 2020.You asked the Plan to pay for the extraction. You say that this extraction was required to remove a dead wisdom tooth. You also say that this service was a medical necessity because you cannot afford to get an infection.The Plan denied your request. The Plan says this service is not a 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 extraction provided on January 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 21, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 and the referring physician are not network providers with the Plan. The Plan did not pre-approve the services 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 laboratory services provided on February 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the correction of hallux valgus provided on December 11, 2019.
You asked the Plan to waive the coinsurance for the correction of hallux valgus. You say that you should only owe 20% coinsurance and disagree with the charges. 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 30% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities. You received the correction of hallux valgus on December 11, 2019. The allowed amount is $3,150.32 and 30% of that is $945.10. You have been asked to pay the total coinsurance amount of $945.10 for the correction of hallux valgus. The correction of hallux valgus falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 coinsurance for the correction of hallux valgus provided on December 11, 2019.
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on January 2, 2020.
You asked the Plan to pay for eye refraction. You say that you were advised to see this provider. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is not covered by Medicare. The Plan also says that this claim has been processed and paid under your Medicaid (Medi-Cal) benefits.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on January 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance oxygen and oxygen supplies (A0422) unlisted
ambulance service (A0999 x2) electrocardiogram, routine ECG (93005) rhythm ECG (93041) and ALS
specialized service disposable supplies (A0394) provided June 20, 2019.
You asked the Plan to pay for the ambulance services. You say that this was an emergency ambulance transport
and you are appealing the denial stating payment is not allowed for this service when performed at this place of
service. The Plan denied your request. The Plan says payment for these items is included in the transportation
fee. Medicare does not allow for separate billing of these services and supplies.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan follows the same rules.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to
pay for ambulance oxygen and oxygen supplies (A0422) unlisted ambulance service (A0999 x2)
electrocardiogram, routine ECG (93005) rhythm ECG (93041) and ALS specialized service disposable supplies
(A0394) provided June 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on February 17, 2020.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you were told that you did not have to pay out of pocket for your fillings and x-rays. You also say that you cannot afford to pay out of pocket for these services. The Plan denied your request. The Plan says this service is not covered by 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 complete series of intraoral x-rays (D0210) provided on February 17, 2020.
Your complaint about being misled by 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a mental health counselor.You asked the Plan to pre-approve these services. You say that you have been seeing this provider for years.The Plan denied your request. The Plan says the provider is not covered.The Plan must follow Medicare rules. The rules say that a mental health counselor is not eligible to participate in Medicare.We looked at the file and Medicare rules. The requested provider is a licensed mental health counselor. This provider type is not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approvea referral to a mental health counselor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for the enrollee.
You asked the Plan to pre-approve a power seat elevation feature. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. The plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous (IV) iron sucrose infusion for the enrollee.
You asked the Plan to pre-approve the infusion. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 the infusion. Our reviewer says that the requested infusion is not medically reasonable or necessary. Our physician reviewer found the documentation does not support that iron sucrose is medically reasonable or necessary for the enrollee. Her iron saturation levels have increased from 10% to 14% from February, 2020 to May, 2020 on oral iron replacement. Continued oral iron replacement appears to be the most reasonable approach based on these records. 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 infusion have not been met. Therefore, we decided that the Plan does not have to pre-approve intravenous (IV) iron sucrose infusion for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings and related supplies identified with code A6530 and E1399 that were issued on January 9, 2020.
You asked the Plan to pay for the compression stockings. You say that you had a laser procedure on your legs and was required to wear the compression stockings. You chose a medical supply store that sold them at a much lower price. The Plan denied your request. The Plan says these items are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are non-covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings and related supplies identified with code A6530 and E1399 that were issued on January 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Vitamin D 25 hydroxy testing provided on February 24, 2020.
You asked the Plan to pay for Vitamin D testing. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not a Medicare benefit for the diagnoses listed on the claim.
The Plan must follow Medicare rules. Medicare rules say that lab testing with procedure code 82306 is only covered when billed with certain, specific diagnosis codes. We looked at the file and Medicare rules. This lab test was not billed with a covered diagnosis code. Based on this information, we decided that Medicare rules for coverage of Vitamin D testing have not been met. Therefore, we decided that the Plan does not have to pay for Vitamin D 25 hydroxy testing provided on February 24, 2020.