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

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), topical application of fluoride varnish (D1206), prophylaxis - adult (D1110), bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic image (D0230) provided December 7, 2020.
You asked the Plan to pay for the periodic dental exam, fluoride application, dental cleaning, bitewing x-rays and intraoral x-rays. You say that you have previously had services from this dentist covered. The Plan denied your request. The Plan says this provider has opted out of provider and therefore the services rendered are not covered.
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 the periodic
dental exam, fluoride application, dental cleaning, bitewing x-rays and intraoral x-rays when the services are provided by a licensed dental provider who accept Medicare patients and has not opted out of Original Medicare. We looked at the file and Medicare rules. In this case the provider who rendered the services has opted out of Medicare. Based on this information, we decided that the Plan's rules for coverage of the periodic dental exam, fluoride application, dental cleaning, bitewing x-rays and intraoral x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), topical application of fluoride varnish (D1206), prophylaxis - adult (D1110), bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic image (D0230) provided December 7, 2020.
Your complaint about poor customer service and a discrepancy in how previous claims from this provider were processed 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
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 inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The enrollee is undergoing a planned left reverse total shoulder arthroplasty. The enrollee is medically stable and has an appointment with Cardiology for preoperative medical clearance assessment to undergo this elective procedure. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. The record does not show that at the time of inpatient admission the admitting physician reasonably expects that the patient's necessary hospital care would span two midnights. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transportation (A0425, A0427) provided on October 16, 2020.
You asked the Plan to pay for the ambulance services. You say that the ambulance transportation was medically necessary. The Plan denied your request. The Plan says the information provided at the time of the appeal does not support medical necessity for ambulance transport.
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 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 ambulance services. Our reviewer says that the ambulance transportation is not supported by medical necessity. Our physician reviewer found that the enrollee was running a fever and was emergency transported with advanced life support. The emergency medical services exam reported that the enrollee, "feels warm to touch but otherwise normal." The enrollee was hemodynamically stable with stable vital signs. Documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this
enrollee. The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on October 16, 2020. 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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transportation (A0425, A0427) provided on October 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on December 23, 2020.
You asked the Plan to pay for the cardiovascular risk assessment panel. 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 a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129, and L36523 to support their denial. However, LCD L36139, L36129, and L36523 are not valid for the provider's billing state of Florida. Therefore, we are unable to use LCD L36139, L36129, and L36523 to substantiate our decision. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on December 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says the enrollee can be treated in a lower level of care, such as outpatient.
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 admission. Our reviewer says that
the requested admission is not medically reasonable or necessary. Our physician reviewer found there is no evidence of an individualized treatment plan. It does not appear that active treatment is taking place. It does not appear that the services for the dates in question are reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. The health plan's denial of continued inpatient psychiatric services appears appropriate. The enrollee could be treated in a lesser restrictive setting, as he was not showing any suicidal or homicidal ideation. There is no evidence of auditory or visual hallucinations, or aggressive behaviors. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient mental health facility for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided on October 9, 2020 by
an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the enrollee is on a fixed income. The Plan
denied your request. The Plan says the claim processed correctly.
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 provider in this case was not a network provider with the Plan at the time the services were provided. 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 the ophthalmology services
provided on October 9, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bronchial thermoplasty (BT) treatments.
You asked the Plan to pre-approve the BT treatments. You say that this is a proven treatment that is expected to
help the enrollee's severe asthma. The Plan denied your request. The Plan says this is excluded from coverage
by National Coverage Determination (NCD) 240.3.
Please note: Maximus reviewed the NCD referenced by the Plan and consulted with our medical director. We
found that this NCD does not apply to the services at issue in this case. The heat treatment modalities cited in
the NCD are different than those used in the treatment at issue. As such, the national non-coverage policy for
these does not apply to bronchial thermoplasty. For this reason, we reviewed the treatment for medical
necessity for this individual patient.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the BT treatments. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the patient does not meet clinical criteria for BT. The patient has a significant
smoking history, more than 10 pack-years, and may have chronic obstructive pulmonary disease (COPD). His
body-mass index (BMI) is also greater than 35 with a first forced expiratory volume (FEV1) that is less than
60% of predicted. Patients with these characteristics were excluded from the clinical trials of BT, and therefore
the safety and efficacy demonstrated in those trials may not apply to this patient.
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 BT treatments have not been met. Therefore, we decided that the Plan does
not have to pre-approve bronchial thermoplasty (BT) treatments.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided from September 1, 2018,
through September 29, 2018.
You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says the claim
denied due to lack of timely filing.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the outpatient services was not filed until October 15, 2019. This means that
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for outpatient services provided from September 1, 2018, through
September 29, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug provided on November 30, 2020.
You asked the Plan to pay for the self-administered drug. You say that you would like to appeal this drug. The Plan denied your request. The Plan says self-administered drugs do not qualify for reimbursement under your Part A and Part B benefits.
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 pay for the self-administered drug provided on November 30, 2020.
Benefits for the self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network
provider.

You asked the Plan to pre-approve the office services. You say that the other doctors are too far away. The Plan
denied your request. The Plan says there are in-network providers that can render the 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 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 the office
services to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction device

You asked the Plan to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869).

You say that the enrollee has chronic low back pain has failed conservative treatment approaches. The Plan denied your request. The Plan says there are not enough studies to show this device is safe and effective.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). 

Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Interspinous process spacers remain experimental at this time. More research is needed to show safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction device
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing provided on October 9, 2020.

You asked the Plan to waive the copayment for lab tests. You say that this was bloodwork requested by your doctor for your wellness exam. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $35 copayment for lab tests. 

You have been asked to pay the allowed amount of $23.95, which is less than the $35 copayment for lab tests. Lab tests fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory testing provided on October 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an electroencephalogram (95822) provided on October 13, 2020.
You asked the Plan to pay for an electroencephalogram. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with the correct code.
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 95822 is electroencephalogram (EEG); recording in coma or sleep only.
We find that CPT code 95822 is not supported in the medical record. Specifically, the records show that the recording was not performed in a coma or a sleep study. Based on this information, we decided that Medicare rules for coverage of an electroencephalogram have not been met. Therefore, we decided that the Plan does not have to pay for an electroencephalogram (95822) provided on October 13, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided on October 1, 2020.

You asked the Plan to pay for the services provided. You say that the enrollee was seen twice on the same day. The Plan denied your request. The Plan says the line item is an exact duplicate.

The Plan must follow Medicare rules. Medicare rules say that claim lines that have been determined to be exact duplicates of another claim or claim line are denied.

We looked at the file and the rules. The claim at issue is a duplicate of a previously billed and paid claim. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room services provided on October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a standard wheelchair (K0001) with elevating leg rests (K0195) provided on January 16 to March 16, 2021, by an out of network provider.

You asked the Plan to pay for a standard wheelchair with elevating leg rests. You say that you would like reconsideration of the denied claims. The Plan denied your request. The Plan says rules for out of network care have not been met.

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 at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for a standard wheelchair (K0001) with elevating leg rests (K0195) provided on January 16 to March 16, 2021, by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections (J0897) provided January 13,
2021.
You asked the Plan to waive the coinsurance for the injections. You say that the copayment should be waived.
The Plan denied your request. The Plan says the correct coinsurance 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 20%
coinsurance for Part B drugs.
You have been asked to pay a 20% coinsurance for the injections. The injections fall within the Part B drugs
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 injections (J0897) provided
January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump.
You asked the Plan to pre-approve a fluid circulating cold pad with pump, any type (E0218). You say that the device will help you manage pain and swelling after your procedure. The Plan denied your request. The Plan says this device is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. This device is statutorily non-covered. Based on this information, we decided that Medicare rules for coverage of a fluid circulating cold pad with pump, any type (E0218) have not been met. Therefore, we decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump.