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

We decided that the Plan does not have to pay for the resin-based composite - two surfaces, anterior (D2331) and the resin-based composite - three surfaces, posterior (D2393) provided December 7, 2020.

You asked the Plan to pay for the additional resin-based composites. You say that you were told that the frequency limit is not per code and all three fillings should be covered. 

The Plan denied your request. The Plan says the Plan has covered one resin-based composite which fulfills the frequency limit for the service and therefore the remaining composites are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the additional resin-based composites when the services are medically necessary and reasonable. 

We looked at the file and Medicare rules. The Plan has provided documentation showing that one resin-based composite has already been covered by the Plan. Based on this information, we decided that the Plan's rules for coverage of the additional resin-based composites have not been met. Therefore, we decided that the Plan does not have to pay for the resin-based composite - two surfaces, anterior (D2331) and the resin-based composite - three surfaces, posterior (D2393) provided December 7, 2020.

Your complaint about potentially receiving misinformation from a plan representative 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve image-guided radiation therapy (IGRT).

You asked the Plan to pre-approve IGRT. You say that the enrollee's kidney condition will complicate radiation. The Plan denied your request. The Plan says that there is no current research showing the enrollee's cancer responds better to this type of treatment.

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 IGRT. Our physician reviewer found that for this enrollee, daily imaging would be to verify position prior to every fraction. Generally, the dose with palliative radiation is low, such that the normal tissue exposure risks are low, and IGRT is not needed. For this enrollee, there is a plausible rationale for IGRT, as the treatment field is in close proximity to her kidneys, atrophic left kidney, and susceptibility of the kidney to radiation damages with doses in excess of 20 Gy. IGRT would be justifiable to verify target position, allow for smaller margins to treat the spine, and therefore allow for better sparing of the kidney. It is plausible that IGRT will benefit this enrollee. Therefore, the requested services would be would be furnished in accordance with accepted standards of practice, 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 IGRT have been met. Therefore, we decided that the Plan has to pre-approve image-guided radiation therapy (IGRT).

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 23, 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 laboratory services provided on October 23, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator rendered on January 8, 2021.
You asked the Plan to waive the coinsurance for these services. You say that the charges are a financial hardship. The Plan denied your request. The Plan says the coinsurance was 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 20% coinsurance for Medicare-covered DME items.
Review of the file shows that you received an oxygen concentrator on January 8, 2021. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-covered DME items benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the oxygen concentrator rendered on January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 19, 2020 by a non-network 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 a non-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 referring provider 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 laboratory services provided on October 19, 2020 by a non-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor.
You asked the Plan to pre-approve a Freestyle Libre 2 Sensor. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 2 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tramadol tablets.
You asked the Plan to pre-approve self-administered drug. You say that the enrollee is in pain and needs this medication. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve tramadol tablets.
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing.
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 are not covered.
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing.
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve Lucentis (J2778).
You asked the Plan to pre-approve Lucentis. You say that this drug is medically necessary. The Plan denied your request. The Plan says that step therapy 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 Lucentis. Our reviewer says that step therapy criteria has been met in this case. Our physician reviewer found the enrollee is an 82-year-old man with age related macular degeneration. The request is for Lucentis for the right eye. In this case, the enrollee has received therapy with the requested drug through a sample. A sample constitutes an administration under the plain language of the statute. The enrollee is receiving the requested drug. The elements of step therapy have been satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lucentis have been met. Therefore, we decided that the Plan has to pre-approve Lucentis (J2778).
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery backup for CPAP.

You asked the Plan to pre-approve the backup. You say that you often lack electricity service. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

A backup battery is not considered a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a battery backup for CPAP.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for lymphatic mapping (93702) provided to the enrollee on January 27, 2020.

You asked the Plan to pay for this claim. You say that this testing is the standard of care and was medically necessary. The Plan denied your request. The Plan says this testing was not covered at the time the service was provided. 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 Plan must follow Medicare rules. On the date of service in question Medicare had specific regulations in place stating the service provided and billed as code 93702 was not covered and was considered excluded under Medicare claims submissions. While the regulation retired June 30, 2020, it applied at the time of service. Maximus did not review the article for coverage in error. Based on this information, we decided that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for lymphatic mapping (93702) provided to the enrollee on January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown implant (D6058) and a custom fabricated abutment (D6057) for tooth # 19.
You asked the Plan to pre-approve the dental services. You say that you are not able to eat well due to your missing tooth. You say that you need to have your teeth finished. You also say that you understand that crowns are covered. The Plan denied your request. The Plan says the requested dental services are not covered. The Plan says that dental implants are only covered for full dentures.
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 states that this coverage excludes implant pillars ("abutments") that support partial removable prosthesis, fixed prosthesis, crowns and all other components. Therefore, we decided that the Plan does not have to pre-approve a crown implant (D6058) and a custom fabricated abutment (D6057) for tooth # 19.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation 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 substantial uncertainty remains about safety and/or impact on health outcomes.

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 this is considered experimental/investigational because of the wide variation in efficacy in the literature. Therefore, the request is considered not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 12, 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 there is no valid physician order.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. 

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair power seat elevation feature.

You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that the enrollee needs a Group 3 power wheelchair, accessories, and a power seat elevation feature. The Plan denied your request. The Plan says a power seat elevation feature is not primarily medical in nature.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

A power seat elevation feature does not serve a purpose that is primarily medical in nature. This feature is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair power seat elevation feature.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trelegy Aer Ellipta.
You asked the Plan to pre-approve Trelegy Aer Ellipta. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Trelegy Aer Ellipta.
Benefits for Trelegy Aer Ellipta 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: 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 enrollee requires 3 hours of therapy a day provided by a multidisciplinary team. The Plan denied your request. The Plan says the enrollee does not have complex nursing or medical needs requiring an intensive inpatient hospital setting.

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 physician reviewer found that the enrollee was admitted to the acute hospital for surgical repair of a hip fracture after a fall. His medical problems are stable. There are no complex nursing needs. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 78-year-old male with end stage metastatic pancreatic cancer who elected Hospice care; however, hospice care has been revoked and as of May 2021 is resuming Medicare Advantage coverage. In this case, there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Bio-Ice menthol analgesic gel provided on November 20, 2020 billed with code A9900.

You asked the Plan to pay for the Bio-Ice pain relief gel. You say that this was a medically necessary item which does not have a specific CPT code. As such, it should be covered under the code A9900. The Plan denied your request. The Plan says the code A9900 cannot be paid under the Outpatient Prospective Payment System (OPPS).

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Bio-Ice menthol analgesic gel provided on November 20, 2020 billed with code A9900.