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

We decided that the Plan does not have to pay for the laboratory services provided on August 12, 2019, through
November 4, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says this claim was billed with an inappropriate
place of service code.
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory services have not been met. Specifically, the record indicates that the specimen was
obtained in a skilled nursing facility setting, but this claim was billed with a laboratory place of service code.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 12,
2019, through November 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting additional non-emergency transportation trips. The Plan denied your request. The Plan says you have two (2) rides left out of your 40 one-way transportation trips for your 2021 benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. You exhausted your benefit because the 41st trip and beyond is not a covered benefit. Your 2021 says that enrollees must pay a $0 copayment for up to forty (40) one-way trips to plan-approved locations every year. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty services (D7321).
You asked the Plan to pre-approve the alveoloplasty services. You say that you are in pain. You say that you have gone to the dentist repeatedly to have fragments of teeth removed. You say that you have spent all of your money on temporary dentures, which you still owe on. You say that those dentures have been adjust three times with no resolution. You say that the alveoloplasty services are being requested so that you can get proper dentures. The Plan denied your request. The Plan says the services in dispute are not a covered benefit under the enrollee's contract.
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 alveoloplasty services (D7321).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the assessment for hearing aid (V5010) provided October 2,
2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the assessment for hearing aid. You say that you were not aware the hearing aid
assessment would not be covered. The Plan denied your request. The Plan says the routine hearing services
were not rendered by the Plan's routine hearing vendor.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids or related services only when the services are rendered by the Plan's hearing aid vendor.
We looked at the file and the Plan's rules. The file indicates that the hearing aid services were rendered by a
provider other than the Plan's routine hearing vendor. Based on this information, we decided that the Plan's
rules for coverage of the assessment for hearing aid have not been met. Therefore, we decided that the Plan
does not have to pay for the assessment for hearing aid (V5010) provided October 2, 2020, by an out-of-network
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing 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 the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that DecisionDx-Melanoma testing 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 pay for these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of malignant
melanoma in multiple sites. He does not have stage T1b or above melanoma and there is no documented
concern regarding the adequacy of microstaging. The presumed risk for a positive sentinel lymph node biopsy
is not documented to be greater than five percent. The testing does not meet the criteria for coverage and was
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 these services have not been met. Therefore, we decided that the Plan does not
have to pay for the DecisionDx-Melanoma testing rendered on August 12, 2020.
Local Coverage Determination (LCD) L38016 referenced by the Plan is for the incorrect jurisdiction and was
not used in the MAXIMUS determination.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on October 1, 2020.You asked the Plan to waive the copayment forthe specialist office visit. You say that your original appointment from September 16, 2020 was moved to October 1, 2020. You say this was out of your control and the copayment should be waived based on the Plan's COVID cost-share waive for Medicare Advantage. The Plan denied your request. The Plan says you have been chargedthe correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted under Medicare rules). You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows cost-sharing for non-primary care telehealth and office-based services would be processed according to your benefit plan as of October 1, 2020.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 forthe specialist office visit provided on October 1, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor.You asked the Plan to pre-approvethe requested device. You say that checking blood sugars 3 times per day is not needed.The Plan denied your request. The Plan says coverage criteria have not been meet.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are coveredunder certain medical indications.We looked at the file and Medicare rules. The documentation does not indicate that the enrollee performsblood glucose testing at least four times per day, use insulin with at least three daily injections, and requiresfrequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuousglucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore build up (D2950) for teeth # 4and 10.You asked the Plan to pre-approvethe dental services. You say that the core build up is necessary.The Plan denied your request. The Plan says core build up 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-approvecore build up (D2950) for teeth # 4 and 10.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT Code 63650).
You asked the Plan to pre-approve the services. You say that the enrollee has tried several modalities to help control their back pain but none successful. You state the enrollee is an excellent candidate for trial placement of a spinal cord stimulator system. The Plan denied your request. The Plan says the request is not medically necessary because the enrollee's records state they had good relief from their epidural steroid injection, they have not exhausted all other treatment options (late or last resort) and the enrollee's doctor fails to document that they have tried and failed surgical treatment or that they are not a surgical candidate.
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 physician reviewer found the enrollee does not have an evidence based indication for a SCS. The request is 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 percutaneous implantation of neurostimulator electrode array, epidural (CPT Code 63650).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Maxillary Partial Denture (D5213).

You asked the Plan to pre-approve the Maxillary Partial Denture. You say that the partial denture is medically necessary.The Plan denied your request. The Plan says the specific type of partial denture requested is not covered under your 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 Maxillary Partial Denture (D5213).
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 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 you were admitted for a gallbladder abscess, anemia and gastrointestinal bleeding. Your medical conditions are stable. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical therapy and occupational therapy, the documentation does not support the need for an intensive rehabilitation program. Your care needs can be met at a lower 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foremergency care (99284) provided on June 15, 2020.You asked the Plan to waive the copayment foremergency care. You say that because you were sent home withonly antibiotics, as your foot continued to hurt, youshould not have to pay the copayment.The Plan denied your request. The Plan says the claim was processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for Emergency care. You have been asked to pay a $90 copayment for emergency care. This service 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 foremergency care (99284) provided on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided.

You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract withthe 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 servicesat 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 outpatient services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6530.You asked the Plan to pre-approvethe compression stockings. You say that you would like reconsideration because you require the compression stockings for venous insufficiency.The Plan denied your request. The Plan says this is not a covered benefit because it does not meet the statutory definition of a dressing.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530are noncoveredbecause they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6530.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an injection procedure for sacroiliac joint,
anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (27096).
You asked the Plan to pre-approve a sacroiliac injection. You say that you need this procedure. The Plan
denied your request. The Plan says the requested service is not supported by a test, or failed trial of 4 weeks of
treatment.
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 a sacroiliac injection. Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is no CT scan imaging of the SI joints. There is no physical exam of the patient to confirm
the diagnosis. 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 a sacroiliac injection have not been met. Therefore, we decided that the Plan
does not have to pre-approve an injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance
(fluoroscopy or CT) including arthrography when performed (27096).
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 the enrollee was admitted to the current acute care hospital as with trauma after a motor vehicle accident. The enrollee suffered cardiac arrest and needle decompression at the scene. The enrollee appears to be more stable but not improving significantly and requires additional short-term acute care services that would be safe to complete at the current setting. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power mobility device and accessories
(E2311, E2377, E2313, K0842).
You asked the Plan to pre-approve the group 2 power mobility device. You say that the PMD 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 a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 group 2 power mobility device. Our
reviewer says that the requested items are not medically necessary. Our physician reviewer found this patient
does not have a personal mobility deficit that impairs participation in MRADLs. The patient's mobility deficit
can be helped by the use of a walker, cane or manual wheelchair. There is no documentation that the patient
can safely operate a PMD.
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 group 2 power mobility device have not been met. Therefore, we decided
that the Plan does not have to pre-approve a group 2 power mobility device and accessories (E2311, E2377,
E2313, K0842).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe chiropractic manipulations provided from August 5, 2020, to August 24, 2020.You asked the Plan to waive the deductible forthe chiropractic manipulations. You say that you were told the chiropractic treatments were covered. You say you would have gone to an in-network chiropractor if you had known. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is 30% coinsurance for each visit to an out-of-network chiropractor once the $1,250 deductible is met. The chiropractic manipulations you asked the Plan to waive the deductible for falls within the "Chiropractic services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 30% coinsurance for each visit to an out-of-network chiropractor once the $1,250 deductible is met. This cost sharing is a contractual obligation that had not been met at the time the chiropractic manipulations were received from August 5, 2020, to August 24, 2020. Therefore, we decided that the Plan does not have to waive the deductible forthe chiropractic manipulations provided from August 5, 2020, to August 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued use of a continuous positive airway pressure (CPAP) device.You asked the Plan to pre-approvecontinued services. You say that the airflow is intense and dries your mouth out.The Plan denied your request. The Plan says you are unable to tolerate CPAP therapy.The Plan must follow Medicare rules. Medicare rules say that continued coverage of a CPAP device is only covered under certain medical indications. We looked at the file and Medicare rules. The records do not show that the CPAP was used greater than or equal to 4 hours per night on 70% of nights during a consecutive thirty-day period anytime during the first three months of initial usage. Based on this information, we decided thatMedicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued use of a continuous positive airway pressure (CPAP) device