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

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on December 19, 2019 by an out of network dentist.
You asked the Plan to pay for the dental services. You say that you have been seeing this dentist for years. You say that you did not switch to this plan. You also say that this would have been covered under your previous plan. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says care rendered by a provider that is not part of our supplemental dental network is 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not covered when you receive them out of network. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on December 19, 2019 by an out of network dentist.
MAXIMUS Federal Services read your letter and knows that you may have a question regarding your enrollment in the Plan. MAXIMUS Federal Services cannot answer enrollment questions. MAXIMUS Federal Services is sending a copy of your case file and your letter so that it can look into your enrollment question.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (40808, 42100, 41108) provided on December 27, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.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 40808 is "Biopsy, vestibule of mouth". The CPT Code Manual definition of code 42100 is "Biopsy of palate, uvula". The CPT Code Manual definition of code 41108 is"Biopsy of floor of mouth".We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of CPT codes 40808, 42100, 41108, is not supported by the records provided. Our physician reviewer found that while the documentation supports that four biopsy specimens were collected and sent for pathology, the documentation does not clearly describe the performance of the biopsies. Detailed information, such as the amount of anesthesia provided, how the anesthesia was provided, preparation of the area, method of biopsy (punch, incision), repair/closure of the biopsy sites, and the amount of bleeding and the presence/absence of complications, is not documented. Therefore, the documentation is insufficient to support the billing of CPTs 40808, 42100, 41108.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 pay for the services (40808, 42100, 41108) provided on December 27, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that you say you have problems standing without support. The Plan denied your request. The Plan says power seat elevation features are not covered by Medicare or the Plan.
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 item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a limb support system (E1020).
You asked the Plan to pre-approve a limb support system. You say that the enrollee needs this item. The Plan
denied your request. The Plan says that this can't be covered because they have approved code E1028.
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 a limb support system. Our reviewer
says that the requested item is considered medically reasonable and necessary in this case. Our physician
reviewer found the limb support system (E1020) is considered medically necessary as the documentation does
not support that the approved wheelchair legrests are elevating which would be medically reasonable for this
patient given his history of multiple failed knee surgeries and lack of knee flexion to prevent a worsening
flexion contracture. Though the Plan has approved swingaway hardware (E1028) that is included in the limb
support system (E1020), Medicare rules do not support the denial of the limb support system for this reason.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a limb support system have been met. Therefore, we decided that the Plan has to
pre-approve a limb support system (E1020).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room Services provided March
13 to March 14, 2019.
You asked the Plan to waive the copayment for the Emergency Room services. You say that you should be
reimbursed the full amount. The Plan denied your request. The Plan says the correct copayment was 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 $90
copayment for Emergency Care.
You have been asked to pay a $90 copayment for the Emergency Room services. The Emergency Room
services falls within the Emergency Care 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 Emergency Room Services provided March 13 to March 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is medically necessary.The Plan denied your request. The Plan says the requested IRF admission does not meet criteria.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the member is status-post fall and left hip fracture and is a partial weight-bearing. The member's medical conditions appear stable. There are no complex wound care needs. There are no unaddressed medical issues. She does not require medical oversight of her condition at an acute hospital level of care. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment after her surgery. She has a new unilateral lower extremity impairment without identified significant upper extremity impairment and does not require the intensity of an acute level rehabilitation therapy program. The member is limited by her orthopedic precautions which are not scheduled to change in the short-term. She would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the member's condition differently compared with therapy provided at a less intense level.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: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve ILUMYA for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysfor Part B coverage, this drug is subject to step therapy.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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the documentation does not support that the plan's required drugs have been tried and failed. The documentation does not support that Remicade or INFLECTRA, and STELARA would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasound to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the ultrasound provided out-of-network. You say that you need an ultrasound because you are having difficulty emptying your bladder and frequently having to go to the bathroom. The Plan denied your request. The Plan says enrollees must use network providers to get their medical care and services. The Plan says that the only exceptions are emergencies, urgently needed service, and when the network is not available. The Plan says that they have located severe in-network providers who are available and able to perform the requested service.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an ultrasound to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397)
provided to the enrollee on December 4, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the
type and quantity of items ordered and for the frequency of use.
The record shows that documentation submitted did not indicate the provider discussed the need for the billed
supply code, so the billed supply code cannot be verified.
Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833,
L2397) provided to the enrollee on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 14, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 services at issue. 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 subsequent nursing facility care provided on November 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis and diabetic foot supplies (A5501, A5513,
L1851) provided to the enrollee on November 25, 2019.
You asked the Plan to pay for the durable medical equipment. You say that the claim should be paid. The Plan
denied your request. The Plan says the medical records lack proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the physician order and proof of delivery
documentation for the items at issue in this appeal. The record does not contain a valid physician order or proof
of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for
knee orthosis and diabetic foot supplies (A5501, A5513, L1851) provided to the enrollee on November 25,
2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a sleep study.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 that the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that a sleep study is covered when specific criteria are met.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 medically necessary. Our physician reviewer found the enrollee has interstitial lung disease, diastolic heart failure, morbid obesity, and pulmonary hypertension. She has snoring, daytime fatigue, and nighttime awakening, although this was not documented in the clinical visits. She has pulmonary hypertension and if present, OSA could worsen this condition. The sleep study to determine OSA 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 these services have been met.Therefore, we decided that the Plan has to pre-approve a sleep study. 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 pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have chronic SI joint pain and previously had SI joint injections and RFA with excellent pain relief. The requested RFA of the SI joint is considered experimental/investigational in nature and is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean electronic connection.You asked the Plan to pre-approvean electronic connection. The Plan denied your request. The Plan says that there is not a medical need to control these power options through the joystick.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 an electronic connection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. This accessory is not needed for functioning of a standard power mobility device and is a convenience item. Our physician reviewer found that the enrollee's condition does not meet criteria for the electronic connection.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 electronic connection have not been met.Therefore, we decided that the Plan does not have to pre-approvean electronic connection
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve local anesthesia.
You asked the Plan to pre-approve the dental service. You say that your last extraction took 45 minutes. You say that you suffer from anxiety. You say that you felt as if you were having a heart attack. You also say that you do not want to experience that feeling again. The Plan denied your request. The Plan says anesthesia is not 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 anesthesia is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve local anesthesia.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical spine surgery for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your
request. The Plan says medical necessity is not established as there is no evidence of formal pre-operative
conservative 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 surgery. Our reviewer says that the
requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no documentation of a recent trial and failure of physical therapy. More conservative measures
are needed. There are no red flags for surgery.
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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve cervical spine surgery for the enrollee.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) following cardiac surgery that was complicated by a perforated ulcer. The enrollee was intubated/ventilated and subsequently received a tracheotomy. It is unclear if or when the enrollee will be able to undergo ventilator weaning. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve test strips. You asked the Plan to pre-approve the non-preferred brand of test strips. You say that you have problems with the preferred test strips. The Plan denied your request. The Plan says you do not have a medical reason for not using the preferred brand of test strips and meters. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no physician documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve test strips.