Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental health services provided
by a nonparticipating provider from January 3, 2020, to July 23, 2020.
You asked the Plan to waive the copayment for outpatient mental health services. You say that you do not
agree with this copayment. 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 $40
copayment for outpatient mental health care.
You have been asked to pay a $40 copayment for outpatient mental health services. The total amount you are
being asked to pay is $160 ($40 x 4 visits = $160). Outpatient mental health services falls within the outpatient
mental health care 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 outpatient mental
health services provided by a nonparticipating provider from January 3, 2020, to July 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper GI endoscopy provided on
August 3, 2020.
You asked the Plan to waive the copayment for the upper GI endoscopy. You say that you went to the provider
with an expectation that this was a preventive procedure and that it was 100% covered. The Plan denied your
request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325
copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital,
including but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay a $325 copayment for the upper GI endoscopy. The upper GI endoscopy falls
within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and
Ambulatory Surgical Center" benefit category. The medical record shows the endoscopy was performed due to
a history of Barrett's esophagus which makes the endoscopy diagnostic in nature.
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 upper GI endoscopy provided on August 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

Wedecided that the Plan does not have to pre-approvecrown -porcelain fused to noble metal (D2752).You asked the Plan to pre-approvecrown -porcelain fused to noble metal. You say that these services are medically necessary for the enrollee's condition.The Plan denied your request. The Plan says you have exhausted your benefit for this 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. The Plan covers crown -porcelain fused to noble metal once every five years.We looked at the file, and Medicare rules. The file indicates you last received this service in July 2017 and thereby have exhausted your benefit until July 2022. Based on this information, we decided that the Plan's rules for coverage of crown-porcelain fused to noble metal have not been met.Therefore, we decided that the Plan does not have to pre-approvecrown -porcelain fused to noble metal (D2752).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent inj.
You asked the Plan to pre-approve Dupixent inj. You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Dupixent inj.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran optometrist visit (92004) provided June 22, 2020.You asked the Plan to waive the copayment forthe optometry services. You say that the copayment shouldbe waived.The Plan denied your request. The Plan says the correct cost-sharing was 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 $40 copayment for specialist visits. You have been asked to pay a $40 copayment for the optometry services. The optometry services fall within the specialist visits benefit category. This meansthat 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 foran optometrist visit (92004) provided June 22, 2020
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance service and ground mileage provided on May 14, 2020.You asked the Plan to pay forthe ambulance service and ground mileage. You say that the enrollee was not admitted to hospice until after he was readmitted to the nursing home.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe ambulance service and ground mileage provided on May 14,2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing (81162).
You asked the Plan to pre-approve the genetic testing. You say that the genetic testing is medically necessary due to family history. The Plan denied your request. The Plan says the enrollee does not meet criteria for this service to be covered.
The Plan must follow Medicare rules. Medicare rules say that testing of an unaffected Medicare eligible individual or family member is not a covered Medicare benefit. We looked at the file and Medicare rules. No medical records were provided to show that the enrollee has signs or symptoms of breast (invasive or ductal carcinoma in situ (DCIS), ovarian cancer (including fallopian tube and primary peritoneal cancer), pancreatic cancer, or prostate cancer. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (81162).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary tissue conditioning (D5850).
You asked the Plan to pre-approve the maxillary tissue conditioning. You say that the enrollee has missing dentition that should be restored in order to improve mastication and esthetics. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit 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 pre-approve a maxillary tissue conditioning (D5850).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan does not have to pre-approve the requested equipment. 

You asked the Plan to pre-approve an infusion pump and continuous glucose monitor for the enrollee. You say that this equipment is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial stating this enrollee could be an exception to the LCD criteria. The Plan requested a reopen stating the LCD does not allow or mention the possibility of exception for this equipment.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage LCD coverage criteria that must be met for Medicare to provide coverage. Our physician reviewer found the enrollee has complicated diabetes and requires frequent administration and monitoring of blood sugar and that this would be the exception in the Type 2 diabetes patient that insulin pump and CGM would be indicated. However, the LCD was reviewed and does not allow exceptions.  
While it is understood that this equipment would be beneficial for the enrollee's use, the required LCD coverage criteria are not met. The Plan is correct in its argument that the expectation of Medicare is that the LCD be followed unless it specifically states there are instances that would allow any type of deviation from the criteria. Therefore, we decided that the Plan does not have to pre-approve the requested equipment.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forneuromonitoringservices (95885, 95908, 95938, 95957) provided July 8, 2020.You asked the Plan to pay forthe neuromonitoring services. You say that these services were medically necessary.The Plan denied your request. The Plan says these services are not separately payable.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 95885, 95908, 95938, & 95957 are not supported in the medical record. Specifically, the patient was an inpatient at the time services were provided. Payment for these services is included in payment to the facility. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring services have not been met.Therefore, we decided that the Plan does not have to pay forneuromonitoring services (95885, 95908, 95938, 95957) provided July 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory work provided on October 21, 2020.You asked the Plan to waive the copayment forthe laboratory work. You say that you thought the lab was free-standing because it was not physically attached to the hospital. You say you should have a $0 copayment. The Plan denied your request. The Plansays you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearlysays that you must pay a $30 copayment for Medicare-covered laboratory services and diagnostic procedures/tests performed in an outpatient hospital facility. You have been asked to pay a $30 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows the blood work was analyzed by the hospital and the claim was submitted by the hospital.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 forthe laboratory work provided on October 21, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency department visit (99283) provided February 23, 2020.You asked the Plan to pay forthe emergency department visit. You say that the primary carrier has paid all they will pay. Please note from documents enclosed, that your insurance with the primary carrier ended on February 29, 2020.The Plan denied your request. The Plan says send primary carriers Explanation of Benefits.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the primary payer has paid for the emergency services and the balance is the $100 copayment.  Please note,if the provider requesting payment for more than is payable under Original Medicare, you may wish to report this to the CMS Regional Office for the state in which the provider operates.Therefore, we decidedthat the Plan does not have to pay forthe emergency department visit (99283) provided February 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on March 24, 2020 to August 11, 2020 by an out of network (OON) provider.You asked the Plan to pay forpractitioner visits. You say that your provider depends on the facility to verify eligibilityand obtain proper authorization.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 the referring facility is also out-of-network with the Plan.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 forthe medical services provided on March 24, 2020 to August 11, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on September 22, 2020.You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.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 did not pre-approve the servicesat 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 outpatient hospital services provided on September 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forcytopathology services (88120) provided on July 9, 2020.You asked the Plan to pay forcytopathology services. You say that the physician believed that this was medically necessary.The Plan denied your request. The Plan says this service is not supported for the billed diagnosis.The Plan must follow Medicare rules. Medicare rules say that bladder tumor marker FISH testing services should be reported with and appropriate ICD-10 code the supports medical necessity.We looked at the file and Medicare rules. The billed diagnosis, R86.6, does not support the medical necessity of this testing. Based on this information, we decided that Medicare rules for coverage of cytopathology services have not been met.Therefore, we decided that the Plan doesnot have to pay forcytopathology services (88120) provided on July 9, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care provided on February 17, 2020 by an OON provider.You asked the Plan to pay forthe subsequent nursing facility care. You say that the treating physician depends upon the hospital staff to verify eligibility, and to obtain the proper authorization from the enrollee's insurance company.The Plan denied your request. The Plan says this service was rendered by an OON provider. The Plan also says that prior 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 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 forthe subsequent nursing facilitycare provided on February 17, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on September 30, 2020 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available for these services.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. ThePlan 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 forphysician services provided on September 30, 2020 by anout of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation (D7140) and nitrous oxide (D9230) provided on October 1, 2020.
You asked the Plan to pay for the dental services. You say that you had a broken tooth extracted. You say that this required a suture. You say that you needed nitrous oxide as you have elevated blood pressure and white coat syndrome due to the dental surgery. The Plan denied your request. The Plan says the services you received are dental in nature. The Plan also says that the dental services you received are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for limited oral evaluation (D7140) and nitrous oxide (D9230) provided on October 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveSynvisc-One for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe plan's preferred viscosupplements are Orthovisc and Monovisc and don't require prior authorization.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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of Orthovisc or Monovisc. The documentation does not support that the plan's required drugs would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveSynvisc-One for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided from June 23,
2020, through September 24, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says
the enrollee must receive care from in-network providers with the exception of emergency or urgent care,
dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network
provider, which requires prior authorization from the plan.
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 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 subsequent nursing facility care provided from June 23, 2020,
through September 24, 2020.