Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on November 13, 2019. You asked the Plan to pay for lab tests. You say that the ordering physician only submitted information to you to help link the enrollee's sample with the test requisition to perform testing. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because the ordering provider did not submit progress notes needed in order to determine the clinical utility of the testing. 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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. 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 did not specify whether the ordering provider was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice that these services would not be covered by the Plan. Without this information, we cannot determine whether the lab order made constitutes plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for these services is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for laboratory testing provided on November 13, 2019. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on October 31, 2019. 
 
You asked the Plan to waive the deductible for the office visit. You say that you were seen for a routine checkup and the provider charged $240. You say you do not understand what the bill is for if the insurance already paid. 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. Your contract with the Plan says that there is a $750 deductible that applies towards out-of-network office visits.  
 
The specialist office visit you asked the Plan to waive the deductible for falls within the "Physician/ Practitioner services including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards out-of-network specialist office visits. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on October 31, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on October 31, 2019.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approve a plastic surgery consultation. We also decided that the Plan does not have to pre-approve a panniculectomy. You asked the Plan to pre-approve a plastic surgery consultation. You say that this is medically necessary. The Plan says that there is no clear documentation that you meet criteria. The Plan follows Medicare rules. Medicare rules say that when a panniculectomy is performed to alleviate such complicating factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis, and the above symptoms have been present for at least three months and are refractory to usual standard medical therapy, such surgery may be considered reconstructive. 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 plastic surgery consultation. Our reviewer says that you have evidence of functional impairment associated with soft tissue excess of the abdomen that has failed reasonable conservative management. However, the medical records do not show that you have been evaluated by Plastic Surgery. Therefore, a consultation for a Plastic Surgery evaluation for surgical correction does satisfy Medicare medically necessary criteria. However, without a surgical evaluation, the actual procedure would not be medically necessary 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 a plastic surgery consultation have been met. Therefore, we decided that the Plan has to pre-approve a plastic surgery consultation. We also decided that Medicare rules for coverage of a panniculectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a panniculectomy. 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 pay for the drug testing services provided on October 17, 2019. You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records for the billed test. The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for specialist office services provided on January 6, 2020.
You asked the Plan to reduce the copayment for specialist office services. You say that you are requesting a reduction of a $45 copayment for specialist off services to a $15 copayment for an annual eye exam. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received office services on January 6, 2020 from an ophthalmologist. You are asked to pay a $45 copayment for the specialist. 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 reduce the copayment for specialist office services provided on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewings- four radiographic Images (D0274) provided on February 13, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for bitewings- four radiographic Images (D0274) provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 10, 2019 by an out of network (OON) provider. You asked the Plan to pay for optometry services. You say that you did not know that this provider was not in-network with the Plan and it was never explained to you. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained. 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 December 10, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin graft (15260) provided on February 13, 2020. You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided. 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 per visit for outpatient surgery provided at an ambulatory surgical center. You have been asked to pay a $250 copayment for the outpatient surgery provided at the ambulatory surgical center. 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 skin graft (15260) provided on February 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided on January 16, 2020. 
 
You asked the Plan to pay for the radiology services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Medicare says providers should use the diagnosis code for billing that describes the patient's diagnosis, symptom, complaint, condition or problem to the highest level of specificity. In this case, diagnosis code Z53.9 is not supported in the medical records provided. Therefore, we decided that the Plan does not have to pay for the radiology services provided on January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME purchased by the enrollee from August 9, 2019 through August 11, 2019 from a non-Medicare provider. You asked the Plan to pay for the DME. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says this provider does not participate with Medicare. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The provider must be eligible to participate in Medicare. The provider the enrollee purchased DME from is not certified for Medicare and therefore, is not a Medicare-Certified provider. Therefore, we decided that the Plan does not have to pay for the DME purchased by the enrollee from August 9, 2019 through August 11, 2019 from a non-Medicare provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services. 
 
You asked the Plan to pre-approve the inpatient psychiatric services. You say that the records provided support the level of care being requested. The Plan denied your request. The Plan says the clinical information submitted shows that the enrollee has stabilized as much as possible in the acute inpatient setting and continued care at a non-acute, long-term care setting is more appropriate. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.  
 
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 inpatient psychiatric services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on May 18, 2020 with Schizoaffective Disorder Depressed Type and Borderline Personality Disorder. Based upon review of the records provided, it was not expected this enrollee would improve in a reasonable period of time for the dates in question, as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than at a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment. 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 inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional problem focused limited oral evaluation and additional first intraoral periapical x-ray provided on December 4, 2019.
You asked the Plan to pay for the additional problem focused limited oral evaluation and additional first intraoral periapical x-ray. You say that your treating provider is an in-network provider. You also say that the services you received were covered and would like these services to be covered at the in-network rates. The Plan denied your request. The Plan says the benefits for these services had been satisfied and the frequency limitations had been exceeded.
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, exams and are limited to two procedures per calendar year. The record shows that you received a problem focused limited oral evaluation on June 17, 2019 and a periodic oral evaluation on June 20, 2019 and your exams benefit was then exhausted. The contract also says that intraoral x-rays are limited to one set per calendar year. The record shows that you received a first intraoral periapical x-ray on June 17, 2019 and your intraoral x-rays benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the additional problem focused limited oral evaluation and additional first intraoral periapical x-ray provided on December 4, 2019.
Appeal type: Other
Decision: Favorable

 We decided that the Plan has to pre-approve a total knee arthroplasty. 
 
You asked the Plan to pre-approve the total knee arthroplasty. You say that the records provided support the need for the requested services. The Plan denied your request. The Plan says that there is no documentation that the enrollee has failed conservative treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 total knee arthroplasty. Our reviewer says that a total knee arthroplasty is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with complaints of chronic worsening left knee pain. Pain is severe with functional activities. Clinical exam findings are consistent with radiographic evidence of left knee tricompartmental osteoarthritis with severe medial and patellofemoral compartment narrowing, and lateral compartment spurring. The enrollee is status post right total knee arthroplasty with good pain relief. Recent conservative treatment has included activity modification, medications, and knee cortisone injection. Current evidence based medical literature would support total knee arthroplasty for treatment of this enrollee's severe left knee osteoarthritis as safe and effective for pain reduction and functional restoration. Given the severity of her osteoarthritis, additional conservative treatment would not be expected to provide significant pain relief or functional restoration. 
 
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 total knee arthroplasty have been met. Therefore, we decided that the Plan has to pre-approve a total knee arthroplasty.  
 
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: 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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the enrollee's functional level with decreased endurance does not indicate that this therapy must be in an IRF with an intensive level program. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Libre Freestyle Monitor, for the enrollee. You asked the Plan to pre-approve the DME. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been 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 the DME. Our physician reviewer found the enrollee does not meet the Medicare criteria for this DME. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve Libre Freestyle Monitor, for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 17, 2020 by an out of network (OON) provider.You asked the Plan to pay for office visit. You say that you were told that this provider was in-network.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.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 January 17, 2020 by an out of network (OON) provider.Your complaint regarding receiving inaccurate information about the network status of this provider is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus and diphtheria toxoids vaccine provided on January 28, 2020. You asked the Plan to pay for the tetanus and diphtheria toxoids vaccine. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit. In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus and diphtheria toxoids vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the tetanus and diphtheria toxoids vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus and diphtheria toxoids vaccine provided on January 28, 2020.