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

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on November 13, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you believe this service should be covered. The Plan denied your request. The Plan says your comprehensive oral evaluation benefit has been exhausted.
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, comprehensive oral evaluation and is limited to one procedure every three years. The record shows that you received a comprehensive oral evaluation on September 10, 2020 and your comprehensive oral evaluation benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on November 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right knee.
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says an MRI is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an MRI. Our reviewer says that an MRI of the right knee is not medically reasonable and necessary. Our physician reviewer found that detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right knee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee.

You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your
request. The Plan says covered alternatives would be a fixed height or a variable height hospital bed.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered
medically necessary when the patient:

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or

2. Requires attachments which can only be attached to a hospital bed; AND

3. Requires frequent changes in body position and/or has an immediate need for a change in body position.

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 bed. Our reviewer says that the
requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does
not clearly reveal that enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary
bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for
frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary
bed.

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 bed have not been met. Therefore, we decided that the Plan does not have to
pre-approve a semi-electric hospital bed for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional non-emergent medical transportation rides.
You asked the Plan to provide additional transportation rides. You say that you were not told about the limit on one-way rides to locations other than your primary care physician. The Plan denied your request. The Plan says you are covered for up to 48 one-way rides per year to health care related locations other than your primary care physician.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers unlimited rides to your primary care physician and up to 48 one-way rides per year to health care related locations other than your primary care physician. We looked at your request, the records in the case file, and the rules. Specifically, the record shows that your benefit limit is 48 one-way transports per year. Therefore, we decided that the Plan does not have to provide additional non-emergent medical transportation rides.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).

You asked the Plan to pre-approve the maxillary partial denture. You say that you need this denture to be approved for coverage. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.

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, maxillary partial denture (D5213) is limited to one procedure every five plan years. The record shows that you received a maxillary partial denture (D5213) on January 8, 2019, and your maxillary partial denture (D5213) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound care provided from November 3,
2020, to November 24, 2020.
You asked the Plan to waive the copayments for wound care. You say that you did not receive surgical
procedures and feel that the hospital coded the services incorrectly. The Plan denied your request. The Plan
says the claims were processed correctly, and you are being charged the correct 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 $385
copayment for outpatient surgery, including services provided at hospital outpatient facilities.
You received wound care at an outpatient hospital facility from November 3, 2020, to November 24, 2020, for
a total of 4 services. Wound care is considered an outpatient surgical procedure. Therefore, you are responsible
to pay the total allowed amount of $1,273.19, which is less than the total copayment amount.
You have been asked to pay the total copayment amount of $1,273.19 for wound care. Wound care falls within
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers 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 wound care provided from
November 3, 2020, to November 24, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies, gloves, and skin barrier wipes.
You asked the Plan to pre-approve incontinence supplies, gloves, and skin barrier wipes. You say that these
were previously covered under your last health plan. The Plan denied your request. The Plan says these items
are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies, gloves,
and skin barrier wipes.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Core Buildup, Including Any Pins When Required tooth (D2950), Retainer Crown - Porcelain/Ceramic (D6740), and Pontic - Porcelain/Ceramic (D6245).

You asked the Plan to pre-approve core buildup, retainer crown and pontic. You say that the services are necessary. The Plan denied your request. The Plan says these services have exceeded the maximum count allowed per period.

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 core buildup, retainer crown and pontic when the services are provided once every five plan years. 

We looked at the file and Medicare rules. The Plan has provided documentation showing that each of these services have already been covered by the Plan previously within the past five years. Based on this information, we decided that the Plan's rules for coverage of core buildup, retainer crown and pontic have not been met. Therefore, we decided that the Plan does not have to pre-approve Core Buildup, Including Any Pins When Required tooth (D2950), Retainer Crown - Porcelain/Ceramic (D6740), and Pontic - Porcelain/Ceramic (D6245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
You asked the Plan to pre-approve a power seat elevation system. The Plan denied your request. The Plan says the item is non-covered.
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. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve GeneDX genetic testing.
You asked the Plan to pre-approve the requested testing. You say that the test results will guide appropriate medical management and treatment for this enrollee. The Plan denied your request. The Plan says there is no documentation as to how outcomes of testing are going to improve management.
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 requested testing. Our physician reviewer found that there is no evidence to support that identifying a genetic abnormality in this enrollee would affect her care. As such, the requested genetic testing is not medically necessary or reasonable. 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 requested testing have not been met. Therefore, we decided that the Plan does not have to pre-approve GeneDX genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard wheelchair.

You asked the Plan to pre-approve these services. You say that the electric wheelchair will not fit in your car. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a standard wheelchair.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99053) provided on October 25, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services is always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Procedure code 99053 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for this service. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 99053) provided on October 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (K0827, E1028).
You asked the Plan to pre-approve the power mobility device. You say that the power wheelchair is medically necessary. The Plan denied your request. The Plan says coverage rules are not met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power mobility device. Our reviewer says that the requested power wheelchair is not medically necessary. Our physician reviewer found the records do not show that the enrollee is unable to use a manual wheelchair. The plan has stated a bariatric manual wheelchair can be considered. 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 power mobility device have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device (K0827, E1028).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective and is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is a lack of evidence to support that Vertiflex is as safe and effective as the standard of care for decompression of the spine.
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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show the safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided to the enrollee on May 12, 2020.
You asked the Plan to pay for the chest provided to the enrollee. You say that this testing was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated the correct criteria were not applied.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a chest x-ray that was performed on May 12, 2020. The Maximus Physician Reviewer determined that the chest X-ray at issue was considered medically reasonable and necessary in this case. The Plan argues that the enrollee was not at risk and the service is not recommended by the American College of Chest Physicians and the American College of Radiology. The medical records show the enrollee is a 49-year-old woman with a listed diagnosis of Nicotine dependence, unspecified, uncomplicated. All other history was reportedly negative. The x-ray showed no evidence of pneumonia, pleural effusion, or pneumothorax. Our Medical Director has concluded that the Plan is correct in this case. There is no documentation to suggest that the chest x-ray in this case was done for an indication other than screening. The only recommended screening test for lung cancer is low-dose computed tomography. A chest x-ray has not been shown to be medically reasonable and necessary in this setting, as it is not an accepted standard of medical practice, and it has not been shown to be at least as beneficial as existing medically appropriate alternatives. Medicare coverage criteria are not met. 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 chest x-ray, professional component, provided on May 12, 2020 have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray, professional component, provided to the enrollee on May 12, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve additional sessions of laser treatments for the enrollee.
You asked the Plan to pre-approve the additional sessions. You say that this is medically necessary. The Plan
denied your request. The Plan says that the full number of requested treatments cannot be approved.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the additional sessions. Our reviewer
says that the requested services are considered medically reasonable and necessary in this case. Our physician
reviewer found the full number of requested visits is needed due to high severity of the disease 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 additional sessions have been met. Therefore, we decided that the Plan has
to pre-approve additional sessions of laser treatments for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that this is medically necessary. The Plan denied your request. The Plan says this is categorized as hygienic equipment that is not primarily medical in nature.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns with core buildup for teeth #7, 9, and 10.

You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says the dental services are not medically necessary.

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 dental services when the services are medically necessary and reasonable. 

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 dental services. Our reviewer says that the requested crowns and core buildup services are not medically reasonable and necessary. Our physician reviewer found that the documentation provided does not meet the criteria of significant coronal breakdown due to caries or fracture for teeth #7, 9, and 10, for coverage of core buildups and crown restorations. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns with core buildup for teeth #7, 9, and 10.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 14, 2020.
You asked the Plan to pay for the orthosis. You say that you trust that the verification provided will be deemed sufficient to allow verification of the claims at issue and to remit payment for the pending claims as soon as possible. The Plan denied your request. The Plan says the supporting documentation does not match the information sent on the claim.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare has specific coverage criteria for each type of orthosis. Based on the records provided, the enrollee did not meet the criteria needed for the orthosis provided. There is no evidence of an established relationship between the enrollee and the ordering physician. There are no claims on file with the ordering physician listed in the enrollee's claim history from 2019 to present. The documentation submitted does not support that the enrollee received a video or telephonic visit by the ordering physician in order to warrant the codes billed. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup procedure (D2950).

You asked the Plan to pre-approve a core buildup. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan's supplemental dental benefit.

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 core buildup procedure (D2950).