Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 2, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

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 had network providers available who could have provided 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 office visit provided on March 2, 2021 by an out of network (OON) provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to pre-approve SNF care. You say that the enrollee is experiencing weakness and low
endurance with physical and occupational therapy. The Plan denied your request. The Plan says that that the
enrollee appears to be at baseline and there is no documentation of therapy needed 5 days a week.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that SNF
care is medically reasonable and necessary for the enrollee in this case. The enrollee does not have documented
skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is functioning
below his baseline due to gout and iatrogenic hypoglycemia. Daily skilled services are required to establish a
maintenance program and/or to prevent deterioration of the enrollee's condition. Our physician reviewer found
that the enrollee's condition meets Medicare criteria for SNF care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing
facility (SNF) care for the enrollee.
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 pre-approve Cologuard colorectal cancer screening.
You asked the Plan to pre-approve Cologuard. You say that you feel this testing is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested testing.
The Plan must follow Medicare rules. Medicare rules say that the Cologuard test is covered for enrollees that are 50 to 85 years old. We looked at the file and Medicare rules. Review of the file shows that the enrollee is not between 50 and 85 years old. Based on this information, we decided that Medicare rules for coverage of Cologuard have not been met. Therefore, we decided that the Plan does not have to pre-approve Cologuard colorectal cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on November 12, 2020.
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the item at issue 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 pay for a lumbar-sacral orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case according to the coverage criteria established by Medicare. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back. 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-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on November 12, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Udenyca (Q5111).
You asked the Plan to pre-approve Udenyca. You say that the requested drug is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says that the coverage criteria have not been met
for Udenyca.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Udenyca. Our reviewer says that the
requested drug is medically reasonable and necessary. Our physician reviewer found that the enrollee has been
diagnosed with extensive stage small cell lung cancer. The enrollee is currently taking Lurbinectedin. The use
of the requested drug Udenyca is FDA-approved for the enrollee's condition as the risk of neutropenic fever is
>20% with the use of Lurbinectedin. In conclusion, the documentation supports that the requested drug is safe
and effective and otherwise reasonable and necessary for this 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 Udenyca have been met. Therefore, we decided that the Plan has to pre-approve
Udenyca (Q5111).
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the stress echocardiogram you had on January 25, 2021.
You asked the Plan to waive the copayment for the stress echocardiogram. You say that you cannot afford this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 copayment for diagnostic radiology services. You have been asked to pay a $110 copayment for the stress echocardiogram. the stress echocardiogram falls within the diagnostic radiology 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 stress echocardiogram you had on January 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the LTACH level of care 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. Our reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Health Plan. Our physician reviewer also found that the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 LTACH services
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services (G0299).
You asked the Plan to pre-approve home health skilled nursing services. You say that home health skilled nursing care is medically necessary. The Plan denied your request. The Plan says rules for home health skilled nursing care have not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health skilled nursing services.
Our reviewer says that the requested home health skilled nursing care is not medically reasonable and
necessary. Our physician reviewer found based on the medical records provided there is no documentation that
skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve
the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition
and/or prevent deterioration. Records indicate the patient's multiple medical conditions are stable and teaching
with regard to disease process and diet and medication regimen has taken place. Additional skilled nursing
services do not appear to be indicated at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health skilled nursing services have not been met. Therefore, we decided
that the Plan does not have to pre-approve home health skilled nursing services (G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the computerized dynamic posturography sensory
organization test (CDP-SOT) provided on February 28, 2020.

You asked the Plan to pay for the computerized dynamic posturography sensory organization test. You say that
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services
rendered were 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 pay for the computerized dynamic posturography
sensory organization test. Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found the enrollee was evaluated for diabetic
neuropathy. There is no clearly documented dizziness or vestibular dysfunction. The literature states that the
clinical value and effectiveness of computerized dynamic post urography sensory organization testing (CDPSOT)
in the setting of diabetic neuropathy have not been demonstrated in the peer reviewed literature.
Therefore, the enrollee did not meet criteria for the services rendered.

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 computerized dynamic posturography sensory organization test have not
been met. Therefore, we decided that the Plan does not have to pay for the computerized dynamic
posturography sensory organization test (CDP-SOT) provided on February 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical
radiographic image (D0220), an extraction (D7210), and an unspecified preventive procedure (D1999)
provided on June 29, 2020.
You asked the Plan to pay for a limited oral evaluation, an intraoral periapical radiographic image, an
extraction, and an unspecified preventive procedure. You say that you did not know the provider was out-ofnetwork.
The Plan denied your request. The Plan says you are not covered for these services when seen by an
out-of-network provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a limited oral evaluation, an intraoral periapical radiographic image, an extraction, and an
unspecified preventive procedure have not been met. Specifically, services were provided by an out-of-network
provider. The Plan has contracted providers available to provide these services. 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 a
limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220), an extraction (D7210),
and an unspecified preventive procedure (D1999) provided on June 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Denosumab injection (J0897) and the IV therapy provided on October 8, 2020.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the services 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 20% coinsurance of the total cost for Medicare Part B drugs. You have been asked to pay $191.21 ($956.04 x 20% coinsurance) for the Medicare Part B drug injection and IV therapy provided.
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 Denosumab injection (J0897) and the IV therapy provided on October 8, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic test provided by a participating provider on February 8, 2021.

You asked the Plan to waive the copayment for a diagnostic test. You say that this caused you a lot of pain and you should not have to pay for this. 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 $100 copayment for outpatient diagnostic tests/diagnostic tests. 

You have been asked to pay a $100 copayment for a diagnostic test. The correct copayment has been applied to the services that were provided. A diagnostic test falls within the outpatient diagnostic tests/diagnostic tests 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 a diagnostic test provided by a participating provider on February 8, 2021.

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 the office visit and drug test provided on May 13, 2020, by
an OON provider.
You asked the Plan to pay for the office visit and drug test. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 had network providers
available who could have provided 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 office visit and drug test provided on May 13,
2020, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthroscopy services represented by code 29823 provided on January 13, 2021.
You asked the Plan to pay for code 29823. You say that the medical records support the billing of code 29823. The Plan denied your request. The Plan says the medical records do not support the billing of code 29823.
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 29823 is Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]).
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 code 29823. Our reviewer says that the medical records do not support the billing of code 29823. Our physician reviewer found code 29823 is not supported in the records. Specifically, the extent and exact locations of the debridement areas are not described. Therefore, the code is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 29823 have not been met. Therefore, we decided that the Plan does not have to pay for the arthroscopy services represented by code 29823 provided on January 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo and Imlygic.
You asked the Plan to pre-approve Opdivo and Imlygic. You say that the requested drugs are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says medical studies have not proven that the combination of drugs requested would be medically helpful for treatment of the enrollee's problem.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Opdivo and Imlygic. Our reviewer says that the requested drug combination is not medically necessary and reasonable for the enrollee's condition. Our physician reviewer found per compendia and literature the drug combination for the enrollee's condition is experimental/investigational. There is no compendia support for the requested drugs and the request is therefore not medically reasonable and 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 Opdivo and Imlygic have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo and Imlygic.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laboratory services provided to the enrollee on July 7,
2020.

You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your
request. The Plan says the care was not approved in compliance with the health plan's authorization procedures.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
laboratory services provided to the enrollee on July 7, 2020.