Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic imaging and a specialist office visit provided by a participating provider on October 21, 2020.
You asked the Plan to waive the copayment for diagnostic imaging and a specialist office visit. You say that the doctor did not do all of the procedures. The Plan denied your request. The Plan says the correct copayments have been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment and a $50 copayment for physician/practitioner services/specialist and outpatient diagnostic tests/diagnostic tests. You have been asked to pay a $40 copayment for a specialist office visit and a $47.53 copayment for diagnostic imaging, which is less than your copayment amount of $50 for outpatient diagnostic tests. The total amount you are being asked to pay is $87.53 ($40 + $47.53 = $87.53). Diagnostic imaging falls within the outpatient diagnostic tests/diagnostic tests benefit category and a specialist office visit falls within the physician/practitioner services/specialist 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 diagnostic imaging and a specialist office visit provided by a participating provider on October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 16, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges due to the quality of care you received. 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 $35 copayment for each specialist visit. You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on November 16, 2020.
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an implant supported porcelain ceramic crown (D6065).

You asked the Plan to pay for these dental services. You say that these dental services should be covered by the Plan. The Plan denied your request. The Plan says the services provided were not covered under the Plan benefit. Maximus administratively overturned the denial because a Plan contract had not been provided for review. The Plan requested a reopen and provided the required contract information. The Plan stated that the appeal was regarding an implant supported crown on tooth number 29, which is a posterior tooth. The contractual dental benefits do not cover implants on posterior teeth; only anterior teeth are eligible for implant benefits. The 2020 Evidence of Coverage explains implant benefits are only for anterior teeth.

The Plan is correct in this case. Medicare does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 2020 coverage rules apply in this case. Though the Plan offered a dental benefit in excess of Medicare coverage, the requested items and services were not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an implant supported porcelain ceramic crown (D6065).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre 2 sensor kit for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not on an insulin treatment regimen requiring frequent adjustments.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee is not adjusting the insulin dose frequently and is not being treated with three or more doses of insulin daily. The elements of the coverage determination are not satisfied. Therefore, the requested service cannot be recommended.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 2 sensor kit for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Guardant360 genetic testing.

You asked the Plan to pay for genetic testing. You say that this testing helped the enrollee's treating physician determine the optimal treatment pathway for the enrollee. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the enrollee did not have a covered diagnosis for this testing.

The Plan follows Medicare rules. Medicare rules state that Next Generation Sequencing may be covered under certain clinical circumstances.

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 genetic testing. Our reviewer says that this testing meets the Medicare criteria for coverage. Our physician reviewer found molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) NSCLC Guidelines Panel strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Molecular profiling such as with Guardant360 is reasonable and medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have been met. Therefore, we decided that the Plan has to pay for Guardant360 genetic testing.

If the Plan does 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/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the chiropractic manipulation services.

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 that maintenance services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the services were non-covered maintenance services; however, no medical records were received for the services. Without medical records, a determination based on whether the services were medically necessary or non-covered maintenance cannot be supported. Therefore, we decided that the Plan has to pay for the chiropractic manipulation services.

If the Plan does 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/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist visit, and spirometry provided
on June 2, 2020, and June 11, 2020.
You asked the Plan to waive the copayments for a specialist visit and spirometry. You say that you disagree
with the charges. 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 $30
copayment for specialist services. Your contract with the Plan also clearly says that you must pay a $50
copayment for diagnostic procedures and tests.
You had a specialist visit on June 2, 2020. Therefore, you are responsible to pay the $30 copayment.
You received spirometry on June 11, 2020. Therefore, you are responsible to pay the $50 copayment.
The total amount you owe is: $80.
You have been asked to pay the total copayment amount of $80 for a specialist visit and spirometry. A
specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category.
Spirometry falls 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 copayments for a specialist visit, and spirometry provided on June 2, 2020,
and June 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility admission.
You asked the Plan to pre-approve the skilled nursing facility admission. You say that you would like reconsideration because the member is not strong enough to go home without help. The Plan denied your request. The Plan says the needed services can be provided on an outpatient basis in a long term care facility or at home.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found admission to a SNF for inpatient skilled rehab services is not medically necessary. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair of resin partial lower denture base (D5611) and the lower denture reline (D5741) provided on October 26, 2020.
You asked the Plan to pay for the dental services. You say that your Dental Plan offers $2,000 for dental services. You say that you took your dentures in for repair. You say that the services were denied and now you do not have dentures. You say that you do not have money to pay for these services. You also say that you feel it is terrible that what the Dental Plan offered was bogus with no allocated funds in the account. The Plan denied your request. The Plan says repair of resin partial lower denture base is not listed as a covered service. The Plan also says that lower denture reline is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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. The Evidence of Coverage clearly says that any services not listed are not covered. Therefore, we decided that the Plan does not have to pay for the repair of resin partial lower denture base (D5611) and the lower denture reline (D5741) provided on October 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive same services at the current level of care.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on July 9, 2020.
You asked the Plan to pay for the infectious agent detection. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on July 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness, electronic connection, enhanced steering and a power seat elevation feature for the enrollee.

You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan denied your request. The Plan says that the member does not need to operate these power options through the joy stick.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature.

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 items. Our reviewer says that the expandable controller, expandable controller harness, electronic connection and enhanced steering are not considered medically reasonable and necessary in this case. The documentation does not reveal that the patient requires other types of proportional input or non-proportional input devices. The patient does not need to operate 3 or more powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant control. The patient's strength in the upper extremities indicates that the patient can control any power options through their own individual switches. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for the expandable controller, expandable controller harness, electronic connection and enhanced steering.

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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness, electronic connection, enhanced steering and a power seat elevation feature for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal scalings and root planings provided on October 28, 2020.
You asked the Plan to pay for the scaling and planing. You say that you believe this service should be covered. The Plan denied your request. The Plan says this procedure is not a benefit under the dental 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 two periodontal scalings and root planings provided on October 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre sensor for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the prior authorization requirements were not met.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the plan requires insulin use for coverage. Although she might need insulin as evidence by her A1C, she is not using insulin according to the information provider. If the enrollee is using multiple insulin shots by now, this information should be provided.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre sensor for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 surgical repair of a hip fracture after a fall. Medical problems are stable. 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Herceptin Hylecta.
You asked the Plan to pre-approve Herceptin Hylecta. You say that the medication is necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 Herceptin Hylecta. Our reviewer says
that the medication is not medically necessary. Our physician reviewer found there is no documentation
provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse
effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Herceptin Hylecta have not been met. Therefore, we decided that the Plan does
not have to pre-approve Herceptin Hylecta.