Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport provided to the enrollee on September 24, 2020.

You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage criteria for ambulance transport were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

We reviewed the original case file and the reopen request. The Plan is correct in this case. Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. Our physician reviewer found the enrollee had elevated blood sugar. While this may impair the enrollee's own ability to drive, it does not constitute transport by ambulance. Based on this information, we decided that Medicare rules for coverage of this transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transport provided to the enrollee on September 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on December 17, 2020.

You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 71045 is radiologic examination, chest; single view. 

We find that CPT code 71045 is not supported in the medical record. Specifically, this code was billed with modifier 77. The documentation supports that the services were provided by the same procedure as other services billed; therefore, this code requires the modifier 76. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on December 17, 2020.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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 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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from November 16, 2020, through December 23, 2020.

You asked the Plan to waive the copayment for physical therapy. You say that you were informed your visits would be covered with 10% coinsurance which would be $9.90 per visit. You say that you should only owe $148.50. The Plan denied your request. The Plan says the copayments 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 $40 copayment for each Medicare-covered physical therapy and speech-language therapy visit. 

You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is $600 ($40/visit x 15 visits = $600). Physical therapy falls within the "Outpatient Rehabilitation Services" 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 physical therapy provided from November 16, 2020, through December 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial denture (D5214).

You asked the Plan to pre-approve a lower partial denture. You say that you need a replacement due to irritation. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 60 months.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a lower partial denture have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on November 7, 2017. Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns - porcelain fused to high noble metal (D6750) for teeth 19, 21, 23, 28, and 30.

You asked the Plan to pre-approve retainer crowns. You say that the service is medically necessary. The Plan denied your request. The Plan says the requested twelve-unit fixed bridge is beyond the scope of the policy benefit coverage.

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 retainer crowns when there is one missing maxillary anterior tooth or two missing mandibular anterior teeth and the member's overall status would justify consideration.

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 retainer crowns. Our reviewer says that the service is not medically necessary. Our physician reviewer found that there are multiple mandibular teeth missing, only one that is anterior. Other than an x-ray, there are no medical records to review. The documentation is insufficient to determine whether the coverage rule is satisfied. 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 the Plan's rules for coverage of retainer crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve retainer crowns - porcelain fused to high noble metal (D6750) for teeth 19, 21, 23, 28, and 30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) and core buildup procedure (D2950).
You asked the Plan to pre-approve the crown and core buildup. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) and core buildup procedure (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removal of torus mandibularis (D7473 x 2).

You asked the Plan to pre-approve the dental services. You say that you need these services so that you can eat. The Plan denied your request. The Plan says removal of torus mandibularis 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. Therefore, we decided that the Plan does not have to pre-approve a removal of torus mandibularis (D7473 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of an endosteal implant body (D6010) for teeth # 23, 24, 25, and 26.

You asked the Plan to pre-approve the dental services. You say that you need these services. You say that you called to get assistance to file your dental appeal. You also say that the plan representative was rude and unwilling to assist you. The Plan denied your request. The Plan says the surgical placement of endosteal implant body 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. Therefore, we decided that the Plan does not have to pre-approve the surgical placement of an endosteal implant body (D6010) for teeth # 23, 24, 25, and 26. 

Your complaint about your experience with your 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307, G0483) provided on August 5, 2020.

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim was billed with a laboratory place of service code, but the records indicate that the specimen was collected in an office setting.

The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the claim was billed with a laboratory place of service code but the record indicates that the member's face-to-face service was rendered in an office setting. There is a more appropriate place of service code for the services billed. Therefore, we decided that the Plan does not have to pay for the drug testing services (80307, G0483) provided on August 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Positron Emission Tomography (PET) scan.
You asked the Plan to provide coverage for a PET scan. You say that a PET scan is medically necessary. The Plan denied your request. The Plan says The Plan states Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for PET scan imaging. The Maximus Physician Reviewer determined that the requested PET scan was medically reasonable and necessary. The Plan argues that Medicare guidelines state that a biopsy is needed for approval of a PET scan. Our Medical Director has concluded that the Plan is correct in this case. The Medicare coverage criteria for a PET scan for Oncologic Conditions, does not provide coverage for a PET scan for the evaluation of an undiagnosed lung nodule without biopsy. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to provide coverage for Positron Emission Tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) for the
enrollee.
You asked the Plan to pre-approve the device. You say that the documentation supports a lymphedema
diagnosis, and unique characteristics which preclude the use of a basic device. The Plan denied your request.
The Plan says this is 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 the device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee does not have lymphedema of the chest, trunk, or abdomen or unique characteristics that
would indicate the segmented pump over a standard pump. There is no documentation of four week trial with failure of a standard pump. The progress note on 3/31 states: Improvement shown with manual lymph drainage as evidenced by measurements due to use of pressure garments, and pump at 40mmHg. Mobility has improved, increased comfort, decreased swelling and increased energy. There are measurements from 3/9/21 through 3/29/21 of the BLE from a lymphedema clinic which show objective decrease in size from 3/9/21 to 3/29/21 due to pump at 40mmHg and pressure garments. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vestibuloplasty ridge extension (D7340).

You asked the Plan to pre-approve a vestibuloplasty. You say that this service is necessary for you to get dentures. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan's supplemental dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a vestibuloplasty ridge extension (D7340).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the brain for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says there is no complete neurologic exam documented.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found in this case, the enrollee was seen at an emergency room for "twitching" that was not visible but "all inside of her." The enrollee was seen in follow up by her primary care provider. Neurologic review of systems was unremarkable. No neurologic examination was performed. The available documentation does not establish the medical reasonableness or necessity of the requested service as defined by Medicare rules. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the brain for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission should be
approved. The Plan denied your request. The Plan says the arthroplasty procedure has been approved, but the
associated inpatient stay remains denied.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more. Additionally, the planned procedure listed under CPT code 27447 is not listed on the CMS Inpatient
Only List.
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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the documentation indicates that the health plan must follow CMS rules and guidance
per Medicare Benefit Policy Manual Chapter 1 and the CMS Inpatient Only List. The enrollee is medically
stable and has been provided medical clearance to undergo this elective procedure. The planned procedure
listed under CPT code 27447 is not listed on the CMS Inpatient Only List. The arthroplasty procedure is
currently approved as an ambulatory outpatient procedure. The review has determined that the record does not
show that at the time of inpatient admission the admitting physician reasonably expected that the patient's
necessary hospital care (including earlier ED and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a teeth cleaning (D1110) provided on November 10, 2020.

You asked the Plan to pay for a teeth cleaning. You say that you would like the Plan to pay for the service. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 6 months.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a teeth cleaning have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on June 2, 2020. Therefore, we decided that the Plan does not have to pay for a teeth cleaning (D1110) provided on November 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nutritional formula.
You asked the Plan to pre-approve the nutritional formula. You say that the nutritional formula is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that nutritional formula is covered when 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 nutritional formula. Our reviewer says that the nutritional formula is not medically necessary. Our physician reviewer found the patient must have a permanent impairment of long and indefinite duration (ordinarily at least 3 months). The documentation provided does not meet these criteria. 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 nutritional formula have not been met. Therefore, we decided that the Plan does not have to pre-approve nutritional formula.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildups (D2950 x2).

You asked the Plan to pre-approve core buildups. You say that the services are medically necessary. The Plan denied your request. The Plan says these services are not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core buildups (D2950 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fixed dental bridge (D5213, D5214, D6245, D6740).

You asked the Plan to pre-approve the fixed bridge. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 fixed bridge when the services are medically necessary and reasonable.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the fixed bridge. Our reviewer says that the requested fixed bridge is not medically necessary. Our physician reviewer found there are no missing anterior teeth in the arch. There is no evidence of a documented physical or neurological disorder that would meet coverage criteria for a fixed bridge.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the fixed bridge have not been met. Therefore, we decided that the Plan does not have to pre-approve a fixed dental bridge (D5213, D5214, D6245, D6740).