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

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the abdomen and pelvis (74177) provided on September 7, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $250 copayment per day for Medicare-covered diagnostic radiology services. You have been asked to pay a $250 copayment for the Medicare-covered diagnostic radiology service provided. 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 the computed tomography (CT) scan of the abdomen and pelvis (74177) provided on September 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pharmacogenetic testing provided on August 15, 2020.
You asked the Plan to pay for the pharmacogenetic testing. You say that you would like reconsideration
because this testing can affect clinical decisions on a member's substance use that affects other medical
conditions. The Plan denied your request. The Plan says if a single procedure is performed, only one
HCPCS/CPT code with one unit of service may be reported for the procedure.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, the pharmacogenetic testing, was requested solely for screening purposes. The
documentation does not show that the requested pharmacogenomic testing was ordered due to any
signs/symptoms of a drug reaction. There is no evidence that the testing was provided for therapeutic decision-making
regarding the need for the use of any specific drug. Therefore, we decided that the Plan does not have
to pay for pharmacogenetic testing provided on August 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone replacement grafts for ridge preservation (D7953).
You asked the Plan to pre-approve the bone replacement grafts. The Plan denied your request. The Plan says this service 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone replacement grafts for ridge preservation (D7953).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Denosumab injection (J0897) provided
on September 16, 2020
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to
the service provided.
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 Part B non-chemotherapy prescription drugs.
You have been asked to pay $238.81 (Plan allowed amount of $1,194.06 x 20% coinsurance) for the Medicare
Part B non-chemotherapy drug injection provided. 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 Denosumab injection (J0897) provided on September 16, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for immunotherapy service provided on July 27, 2020.
You asked the Plan to waive the copayment for specialist visit. You say that this cost-share was not on the Evidence of Coverage or Annual Notice of Change for 2020. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $35 copayment for specialist visit. You have been asked to pay the allowed amount of $10.36, which is less than the $35 copayment for specialist visit. Specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for immunotherapy service provided on July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 14, 2019 by an outof network (OON) provider.You asked the Plan to pay forthe OON services. You say that there are no in-network doctorswho can treat the enrollee in the facility.The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain services.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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in thisappeal. 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 forthe medical services provided on November 14, 2019 byan out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

e decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.You asked the Plan to pre-approvecontinued services. The Plan denied your request. The Plan says the enrollee does not require skilled care on a daily basis.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.Continued services beyond January 17, 2021, were requested. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determineif the Plan was correct in denying the request to pre-approve continued services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications, and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a maximal assist level with functional mobility. She required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. She does not require skilled nursing or therapy services on a daily basis. She does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 continued services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 18 and 20.
You asked the Plan to pre-approve the core build up. You say that the crowns cannot be done without the build
up. You say that the build up is necessary. You also say that the tooth does not have enough structure to
support the crown without build up. 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. The Customer Handbook clearly states that if a dental item or service
is not listed in the benefit chart or listed with NC, then it is not covered. Therefore, we decided that the Plan
does not have to pre-approve core build up (D2950) for teeth # 18 and 20
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 3, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics.
The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on July 3, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided on August 27, 2020.
You asked the Plan to pay for an x-ray. You say that this should be covered. The Plan denied your request. The Plan says payment for this service is included in a previously paid procedure.
The Plan must follow Medicare rules. Medicare rules say that a pleural drainage procedure (e.g., CPT codes 32556, 32557), thoracentesis procedure (e.g., CPT codes 32554, 32555), or chest tube insertion procedure (e.g., CPT codes 32550, 32551) is often followed by a chest radiologic examination to confirm adequacy of the procedure, lack of complications, or the proper location and positioning of the chest tube. A chest radiologic examination CPT code (e.g., 71045, 71046) shall not be reported separately for this radiologic examination. We find that CPT code 71045 is not supported in the medical record. Specifically a thoracentesis procedure (32555) was performed on the same date of service and a chest radiological examination should not be reported separately. Based on this information, we decided that Medicare rules for coverage of an x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided on August 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that 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 patient appears to be more stable but requires additional non-complex short-term acute care services which can be safely completed at the current facility. The patient does not require servicesat the LTACH that are not already available and covered at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed.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-approveLTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Planto pre-approveIRF care. You say that you believe that you would benefit fromthis level of care.The Plandenied your request. The Plansaysthe criteria for IRF admission are not met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonableand 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 complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for atrial fibrillation in November 2020. She had a two week stay in skilled nursing after the acute stay and now has been discharged home. She has fatigue and weakness after aninfection with COVID diagnosed on 12/17/2020. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs.While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe retreatment of a previous root canal (D3346), post removal (D2955), and the unspecified preventive service (D1999) provided on August 11, 2020.You asked the Plan to pay forthe retreatment of a root canal, post removal, and unspecified preventive service. You say that your tooth was broken. You say that in order to fix it, your bridge had to be re-remanded and reapplied. You say that the bridge was broken and loose. You also say that it had to be stabilized and necessitated additional root canal work.The Plan denied your request. The Plan says the retreatment of a previous root canal is not listed as a covered service. The Plan says post removal is not listed as a covered service. The Plan says that dental services that are not listed are not covered. The Plan also says that you were not billed for the unspecified preventive service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are not covered. Additionally, the provider is not billing you for the unspecified preventive service.Therefore, we decided that the Plan does not have to pay forthe retreatmentof a previous root canal (D3346), post removal (D2955), and the unspecified preventive service (D1999) provided on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on July 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.
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 outpatient services provided on July 14, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on September 8, 2020.
You asked the Plan to pay for the dental service. You say that you last had bitewing x-rays on August 15, 2019. You also say that it has been more than 1 year since then. The Plan denied your request. The Plan says 1 bitewing x-ray procedure is covered per plan year. The Plan says that the frequency limit for this service has been exceeded.
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 frequency limit of 1 bitewing x-ray procedure per plan year has been exceeded. The record shows that the Plan paid for a bitewing x-ray that you received on August 13, 2020. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on September 8, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan does not have to pre-approve Erbitux (Cetuximab) for the enrollee.

You asked the Plan to pre-approve Erbitux (Cetuximab). You say that this drug is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Erbitux (Cetuximab) in a regimen with Capecitabine and Oxaliplatin. The Maximus Physician Reviewer determined that per the NCCN compendia, Erbitux is medically necessary for KRAS wild type metastatic colon cancer. 
The Plan requested a reopen stating the regimen of Capecitabine and Oxaliplatin is not recommended with Cetuximab, and no other compendia or clinical trial support for Capecitabine and Oxaliplatin plus Cetuximab could be identified in the setting of first-line treatment of metastatic adenocarcinoma of the colon. Our Medical Director says the medical records show the enrollee is a 71-year-old man with a history of malignant neoplasm of the colon. The enrollee now has stage IV cancer with two lesions in the liver. The Plan is correct in this case. Erbitux (Cetuximab) in a regimen with Capecitabine and Oxaliplatin is not FDA-approved for the enrollee's diagnosis. The use of Erbitux (Cetuximab) in a regimen with Capecitabine and Oxaliplatin is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, 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 Erbitux have not been met. Therefore, we decided that the Plan does not have to pre-approve Erbitux (Cetuximab) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for train-of-four testing (95999) provided June 25, 2020.
You asked the Plan to pay for the train-of-four testing. You say that the services were medically necessary. The
Plan denied your request. The Plan says this code is not eligible for separate payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 95999 is not supported in the medical record. Specifically, the neuromonitoring
services are considered essential to the primary procedure and payment is bundled with the primary procedure.
Based on this information, we decided that Medicare rules for coverage of the train-of-four testing have not
been met. Therefore, we decided that the Plan does not have to pay for train-of-four testing (95999) provided
June 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug provided on January 9, 2020.
You asked the Plan to waive the coinsurance for the Part B drug. You say that you have been receiving the same injection for three years and have never been billed until now. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of the cost for Medicare Part B chemotherapy drugs and other Medicare Part B drugs.
You have been asked to pay $1,495.69 which is less than the standard 20% of the allowed amount for the Part B drug. The allowed amount is $10,052. The Part B drug falls within "Medicare Part B prescription drugs" 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 Part B drug provided on January 9, 2020.
Our decision is only about the January 9, 2020 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 1, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics.
The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on August 1, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on August 1, 2020.