Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe therapy services with injections (97112, 97016, 97032, 96372) provided on October 13, 2020.You asked the Plan to pay forthe therapy services with injections. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not pre-authorized or emergent. Out-of-network services are not covered except in limited exceptions.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 therapy services with injections (97112, 97016,97032, 96372) provided on October 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the cataract surgeries from June 25, 2020, to July 23, 2020.
You asked the Plan to reduce the copayment for the cataract surgeries. You say that you believed the surgery was done at an ambulatory surgical center and should be charged a $245 copayment. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $295 copayment for surgery services at an in-network outpatient hospital. The enrollee has been asked to pay a $295 copayment for each of the cataract surgeries. The cataract surgeries fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by an outpatient hospital facility.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the cataract surgeries provided from June 25, 2020, to July 23, 2020.
Your complaint about the benefit structure 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: DME/ Orthotics
Decision: Favorable

We decided that the Planhasto pre-approvea UV light cabinet.You asked the Planto pre-approvethe cabinet. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthis is not covered for this condition.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 cabinet. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the use of phototherapy is a standard of care for atopic dermatitis, but office visits for this patient are not feasible.We looked at this physician's review, the file, and Medicare rules. The rules do not say that the light cabinet is only covered for generalized intractable psoriasis. You have a condition that is a standard of care for the requested service. Based on this information, we decided that Medicare rules for coverage of the cabinet have been met.Therefore, we decided that the Planhas to pre-approvea UV light cabinet.If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you require rehab.The Plan denied your request. The Plan says that you can safely receive the services you need 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for respiratory failure and COVID 19 pneumonia. Your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.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 applythe 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 gastrointestinal bleeding. 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora diagnostic mammogram and ultrasound received on August 13, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis applied towards the deductible.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible for covered medical services. The item or service you asked the Plan to pay for falls within the benefit category covered medical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for covered medical services. This cost sharing is a contractual obligation that had not been met at the time the services was received on August 13, 2020. You are responsible for the $655.80 deductible charge, as the deductible was not met at the time of service.Therefore, we decided that the Plandoes not haveto pay fora diagnostic mammogram and ultrasound received on August 13, 2020
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to provide coverage for an out of network urology consultation.You asked the Plan to provide coverage for out of network urology providers. You say that you prefer to see the requested provider.The Plan denied your request. The Plan says this service can be provided in network. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan stated that Maximus overturned the denial stating the Plan was unable to verify if the in-network specialists would be able to accommodate your need for a surgical oncology consult. The Plan has confirmed and provided the names of at least two physicians who can provide treatment for your condition. The Plan is correct in this case. 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 is not a network provider with the Plan. The Plan has multiple network providers available who can provide treatment for your condition. Therefore, we decided that the Plan does not have to provide coverage for an out of network urology consultation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy (S9501) provided on May 7, 2020, through May 13, 2020.You asked the Plan to pay forthe home infusion therapy. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT code S9501 has a status indicator of I and is not valid for Medicare purposes.The Plan mustfollow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S9501 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9501 has a status indicator of I. This means that CPT code S9501 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met.Therefore, we decidedthat the Plan does not have to pay forthe home infusion therapy (S9501) provided on May 7, 2020, through May 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 25, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says it is
important to know which providers are part of our network because, with limited exceptions, while the enrollee
is a member of our plan the enrollee must use network providers to get medical care and services. The only
exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis
services, and cases in which the Plan authorizes use of out-of-network providers.
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
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services provided on October 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on June 1, 2020.
You asked the Plan to pay for the dental services. You say that you were advised the services were covered. The Plan denied your request. The Plan says the services 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 file shows that you received a surgical extraction, and an impacted tooth removal. Although the Plan offers a dental benefit in excess of Medicare coverage, the services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on June 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRepatha Sureclick.You asked the Plan to pre-approveRepatha. You say that the enrollee has shown improvements while on this medication.The Plan denied your request. The Plan says this medication does not fall under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay forself-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-approveRepatha Sureclick.Benefits for Repathamay be available under Medicare Part D.Contactthe 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 pay for surgical services (57425) provided July 21, 2020.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says Registered Nurse First Assistants are not recognized as physicians and are not eligible for payment for this service.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical services (57425) provided July 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe screening digital tomosynthesisfor mammography provided on August 24, 2020.You asked the Plan to pay forscreening digital tomosynthesis for mammography. You say that the Plan should pay this claimas there were multiple studies done.The Plandenied your request. The Plan says a claim was paid and the records do not support an additional study.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 77063-26 is Screening digital breast tomosynthesis, bilateral.We find that CPT code 77063-26 is not supported in the medical record. Specifically, there is not record of an additionalstudy. Based on this information, we decided that Medicare rules for coverage of an additional screening digital tomosynthesis for mammography have not been met.Therefore, we decided that the Plan does not have to pay forthe screening digital tomosynthesis for mammography provided on August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe
gingival inflammation (D4346) provided on August 18, 2020.
You asked the Plan to pay for the scaling. You say that the provider guaranteed you that this procedure would
be covered. The Plan denied your request. The Plan says this service is not covered under the 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 pay for the
scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on August 18,
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Hyaluronan injection (J7325) provided
on September 2, 2020.
You asked the Plan to waive the coinsurance for a Hyaluronan injection. You say that you were not made
aware you would be charged. The Plan denied your request. The Plan says this processed 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 20%
coinsurance for Medicare-covered Part B drugs.
You have been asked to pay a $211.20 coinsurance for a Hyaluronan injection, a Medicare-covered Part B drug
($1,056 allowed amount x 20% = $211.20). 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 a
Hyaluronan injection (J7325) provided on September 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not met.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has age-related osteoporosis without current pathological fracture. The records do not support a history if an osteoporotic fracture or previous treatment, contraindication, or intolerance to zoledronic acid. The Prolia is therefore not reasonable or medically necessary at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay in full for eyeglass frames (V2020) provided.

You asked the Plan to pay in full for the frames. You say that the eyeglass frames should be covered.The Plan denied your request. The Plan says a check for $150 was issued. The plan is not responsible for any amount over $150.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eye wear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan provides a $150 allowance towards eye wear.

We looked at the file and the Plan's rules. The plan provides a vision benefit in the form of a $150 per-year allowance for eyewear. The enrollee is responsible for any amount over $150. The record shows the eyeglasses came to a total of $375. 


The plan has issued a check for the $150 allowance already. Based on this information, we decided that the Plan's rules for coverage of the frames have not been met.Therefore, we decided that the Plan does not have to pay in full  frames (V2020) provided.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided the Plan does not have to pay for a lumbar-sacral orthosis provided to the enrollee on April 13,
2020.
You asked the Plan to pay for equipment provided to the enrollee. You say that this claim should be paid. 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 that Maximus did not apply the correct criteria.
The Plan is correct in this case. The original case file was not decided with a medical review. For the reopen,
we asked our Medical Director to look at the case file and the reopen requires. Our Medical Director says that
at issue is coverage for a lumbar-sacral orthosis. In the original decision Maximus determined that the order
was sufficient to justify coverage of the lumbar-sacral orthosis. The Plan requested a reopen and stated that the
records show physical therapy was recommended, not a brace. The Plan states they have no documentation of
an order or any type of need for an ortho brace. The medical records show the enrollee was evaluated in the
office on February 18, 2020 for falls and back pain. She had a follow up on February 26, 2020 and reported
that she was doing much better. The records show that on April 10, 2020 a mobility back brace was ordered, as
were a mobility knee brace, a suspension sleeve, an ankle brace, and a shoulder immobilizer. However, the
available documentation in the case file does not support that the requested lumbar -sacral orthosis was
medically reasonable and necessary for the enrollee according to the coverage criteria established Medicare.
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 orthosis provided were not met. Therefore, we have decided the Plan does
not have to pay for a lumbar-sacral orthosis provided to the enrollee on April 13, 2020.