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

We decided that the Plan does not have to pay for the medical services provided on August 21, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 medical services provided on August 21, 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 a facet joint injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request is not reasonable or 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 pre-approve the injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review has determined that there has not been at least three months of moderate to severe pain that 
has responded to conservative care. The pain is associated with radiculopathy and there is no documentation 
that indicates that the facet joint is the main source of pain. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a facet joint injection for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan does not have to pay for the definitive drug testing panel of 8-14 drug classes provided on June 25, 2019.

You asked the Plan to pay for the definitive drug testing panel. You say that this was ordered by the treating physician and is considered medically necessary for patient management. The Plan denied your request. The Plan says that the documentation does not support that the 8-15 drug classes described by this panel were tested in this case. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information regarding this claim. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. Medicare rules say that claims for drug testing be accompanied by medical records that support the services billed. The Plan provided records show only 7 classes of drugs were tested. Medicare coverage criteria were not met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing panel of 8-14 drug classes provided on June 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions of tooth #'s 3 and 5 provided on June 16, 2020 by an OON provider.

You asked the Plan to pay for the extractions. You say that you would like these services to be covered by the Plan. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that no benefits are available for procedures performed by OON providers.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the extractions of tooth #'s 3 and 5 provided on June 16, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for limited oral evaluation, three periapical x-rays, the
surgical extraction, two simple extractions, and the unspecified preventive service provided from June 10,
2020, to August 19, 2020.

You asked the Plan to pay more for the dental services. You say that only $75.60 was paid for the services you
received in June 2020, and $28.25 for the services you received in August 2020. You say that you were under
the impression that you would pay 50% after the $100 deductible and if out of network you would pay a little
more. You say that barely anything was paid. You also say that when you received the service a couple years
back, the plan paid much more. The Plan denied your request. The Plan says the provider in this case is out of
network. The Plan also says that the claims processed correctly.

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, you pay 50% for covered dental
services after the $100 deductible has been met. Additionally, out of network providers are allowed to bill you
for the different between what they charge and the amount that the Plan paid. Therefore, we decided that the
Plan does not have to pay more for limited oral evaluation, three periapical x-rays, the surgical extraction, two
simple extractions, and the unspecified preventive service provided from June 10, 2020, to August 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 11, 2020, 
to July 12, 2020. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says 
inpatient care was not medically necessary. 
 
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 pay for the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that the record did not show that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from July 11, 2020, to July 12, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic casts provided on October 26, 2020. 
 
You asked the Plan to pay for the diagnostic casts. You say that prior to receiving this service your provider 
contacted the Plan and confirmed that this procedure was covered. The Plan denied your request. The Plan says 
this service is not covered. The Plan also says that the dental office contacted the Plan on September 2, 2020, 
but no benefits regarding the coverage of diagnostic cases were discussed. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
diagnostic casts provided on October 26, 2020.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the enrollee doesn't feel safe in a nursing home. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.

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. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the services can be obtained at a lower level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs and the beneficiary does not require skilled therapy services on a daily 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 SNF care have not been met. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. This means the service is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses (V2025, V2781) purchased from an out-of-
network provider on May 19, 2020. 
 
You asked the Plan to pay for eyeglasses. You say that you didn't know you didn't have out-of-network 
benefits. The Plan denied your request. The Plan says this is not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are provided by an in-network provider. 
 
We looked at the file and the Plan's rules. Eyeglasses purchased out-of-network are not covered. Based on this 
information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we 
decided that the Plan does not have to pay for eyeglasses (V2025, V2781) purchased from an out-of-network 
provider on May 19, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the walk in shower.

You asked the Plan to pre-approve the walk in shower. You say that you would like reconsideration because this equipment is necessary for the member due to their condition. The Plan denied your request. The Plan says a walk-in shower does not meet the definition of being durable medical equipment.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the walk in shower.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance oxygen and supplies provided during air 
ambulance transport on December 2, 2018 billed with code A0422. 
 
You asked the Plan to pay for the ambulance oxygen and supplies. You say that it is felt that this claim should 
be paid due to medical necessity. The Plan denied your request. The Plan says it was found that this air 
transportation was medically necessary, and payment for the transport and mileage have been approved. 
However, the oxygen is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that separate payment cannot be made for ambulance 
oxygen supplies. This is included in the FS payment for the trip.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance oxygen and supplies have not been met. Therefore, we decided that the Plan does 
not have to pay for the ambulance oxygen and supplies provided during air ambulance transport on December 
2, 2018 billed with code A0422.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia (J0897). You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or 
intolerance to zoledronic acid or has a history of osteoporotic fracture. 
 
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 Prolia (J0897). Our reviewer says that 
criteria is not met. Our physician reviewer found the patient has not tried and failed the required drug. There is 
no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for 
the patient. There is no documentation that the patient has a history of an osteoporosis related fracture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia (J0897) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia (J0897).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nurtec ODT tablets. 
 
You asked the Plan to pre-approve Nurtec ODT tablets. You say that this medication has been effective for the 
enrollee. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the 
enrollee's prescription drug plan. 
 
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 Nurtec ODT tablets.  
 
Benefits for Nurtec ODT tablets 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room (ER) services rendered on September 23, 2020 and September 24, 2020.

You asked the Plan to waive the copayments for these services. You say that you are being charged two copayments. The Plan denied your request. The Plan says the copayments were applied 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 $120 copayment for in-network emergency room services.

Review of the file shows that you received ER services on September 23, 2020 and September 24, 2020. You have been asked to pay a $120 copayment per date of service for these services, for a total of $240. These services fall within the in-network emergency room 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 copayments for the emergency room (ER) services rendered on September 23, 2020 and September 24, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on January 25, 2019.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not filed timely.

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 these services was not filed until November 3, 2020. 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 the services rendered on January 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on February 6, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that all charges, except for therapies, telehealth originating 
site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are 
combined and reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient). 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required 13X 
TOB code. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the services rendered on February 6, 
2020.
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 you need IRF care because it is not safe for you to 
return home. The Plan denied your request. The Plan says your needs could be met in a skilled nursing facility. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
atrial ablation for atrial fibrillation and your course was complicated by pulmonary edema and hypoxemic 
respiratory failure. Your medical conditions are stable. There are no medical needs requiring inpatient 
admission. There are no complex nursing or rehabilitation needs. While the medical record documents a need 
for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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.