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

We decided that the Plan does not have to pay for the root canal (D3310) provided on December 8, 2020.

You asked the Plan to pay for the dental service. You say that you had a tooth in the front, break in half. You say that your old dentist went out of business, so you went to one 3 blocks from your house. You say that you did not go to the dentist. You say that the provider cannot be out of network and exceed your limitation of benefit. You also say that the plan should pay their share of the service. The Plan denied your request. The Plan says providers are paid based on the Maximum Allowable Charge (MAC). The Plan says that the provider in this case is out of network. The Plan also says that out of network providers may bill you for any amount greater than the MAC payment made by the plan to the provider.

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 and root canal is listed as a covered service, dental services that you receive out of network have a higher cost share. The record shows that the Plan paid 50% of the allowed amount for the root canal. Additionally, out of network providers may bill you for any amount greater than the MAC payment made by the plan to the provider. Therefore, we decided that the Plan does not have to pay for the root canal (D3310) provided on December 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with a computed tomography (CT) scan from the skull to mid-thigh.

You asked the Plan to pre-approve a PET CT scan from the skull to mid-thigh. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a PET CT scan from the skull to mid-thigh. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested PET scan is requested for initial anti-tumor treatment strategy in a Medicare beneficiary with adenocarcinoma of the prostate. This is a non-covered indication. The elements of the coverage rule are not satisfied. The requested service is not recommended. 

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 CT scan from the skull to mid-thigh have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) with a computed tomography (CT) scan from the skull to mid-thigh.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 occupational therapy visits.

You asked the Plan to pre-approve 6 occupational therapy visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 6 occupational therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. Based on the available records the enrollee appears to have improved with therapy to the point of being able to manage most basic activities of daily living. Six additional therapy visits as approved by the health plan are reasonable to finalize a home exercise program and then transition to the home exercise program appears appropriate. No additional visits are required. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 occupational therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 19, 2020.

You asked the Plan to pay for the dental service. You say that you needed your crown reattached after it came off. You say that the roots were exposed before the crown was replaced and it soon became infected. You say that you would like the plan to pay for the charges as the appointments were necessary for your health. You say that you could not hold off as the infection was too painful. You also say that the charges will bring an undue burden on your limited income. The Plan denied your request. The Plan says coverage is limited to 1 limited oral evaluation per plan year. The Plan says that the frequency limit 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 and limited oral evaluation is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for the limited oral evaluation that you received on August 17, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transport chair (E1038).

You asked the Plan to pre-approve this item. You say that a transport chair is medically necessary. The Plan denied your request. The Plan says your request does not meet Medicare criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that if a manual wheelchair is only for use outside the home, it will be denied as non-covered, no benefit, as the DME benefit requires use within the home for coverage eligibility. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Specifically, the record indicates that this chair has been requested only for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a transport chair (E1038).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve implantation of a CardioMEMS system.

You asked the Plan to pre-approve CardioMEMS. You say that this is medically reasonable and necessary. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because CardioMEMS is experimental/investigational and substantial uncertainty remains about the comparative effectiveness of CardioMEMS and the long-term impact on health benefits.

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 CardioMEMS. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has class III congestive heart failure symptoms, multiple readmissions for congestive heart failure, and is on a complex diuretic regimen and guideline directed therapy. In spite of this he remains significantly symptomatic with recent and recurrent admissions to the hospital. CardioMEMS pressure sensor monitoring to more meticulously manage his volume status is a medically reasonable option in this enrollee. He fits the Food & Drug Administration (FDA) indications for the device and is clinically similar to the specific patients who showed benefit in symptoms improvement, heart failure class, quality of life, and risk of rehospitalization in the published randomized trials and based on published expert opinion on this device's indications.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have been met. Therefore, we decided that the Plan has to pre-approve implantation of a CardioMEMS system.

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: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve physical therapy visits.

You asked the Plan to pre-approve physical therapy visits. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 physical therapy visits. Our reviewer says that the services are medically necessary. Our physician reviewer found based on the medical records provided there is documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. The available therapy records indicate the enrollee has had slight improvement in his pain from March 5, 2021 to April 9, 2021 and has met two of the three short term goals as outlined by the therapist and four more weeks of therapy twice weekly are recommended. Approved for eight additional physical therapy visits. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy visits have been met. Therefore, we decided that the Plan has to pre-approve physical therapy visits.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upgrade to a shower chair.

You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says this is not considered primarily medical in nature.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

As the shower chair itself is not a covered benefit, upgrades cannot be covered either. Therefore, we decided that the Plan does not have to pre-approve an upgrade to a shower chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hydrocodone-acetominophen.

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 self-administered drugs are not covered.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve hydrocodone-acetominophen.

Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve cardiac catheterization.

You asked the Plan to pre-approve cardiac catheterization. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not been met.

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 cardiac catheterization. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found there is some clinician judgement which must be factored in these situations, and especially given his relatively high pre-test probability of CAD, and the fact that he has not undergone angiography since 2013, it is medically reasonable to consider a repeat left heart catheterization at this time to reassess his coronary anatomy in light of the current persistent and increasingly frequent symptom constellation. This would meet the general medical necessity and reasonableness criteria of the applicable CMS Section 1862(a) rule. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cardiac catheterization have been met. Therefore, we decided that the Plan has to pre-approve cardiac catheterization.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two core buildups, including any pins when required (D2950 x2).

You asked the Plan to pre-approve the core buildups. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan.

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 two core buildups, including any pins when required (D2950 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot inserts (L3020). You say that you have foot pain and need the inserts. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pulpal debridement (D3221) for tooth #10 and periodontal scaling and root planing for 4 or more teeth per quadrant (D4341) for the upper left quadrant.

You asked the Plan to pre-approve pulpal debridement and periodontal scaling and root planing of 4 or more teeth per quadrant for the upper left quadrant. You say that the pulpal debridement service is medically necessary and supported by x-rays. The Plan denied your request. The Plan says pulpal debridement is not covered by Medicare or by the Plan's supplemental dental benefit. The Plan has also approved code D4342 (periodontal scaling and root planing for 1-3 teeth per quadrant) for the upper left quadrant, as code D4341 cannot be approved because there are fewer than four teeth in that quadrant.

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. Additionally, the Plan provided documentation that they pre-approved periodontal scaling and root planing for 1-3 teeth for the upper left quadrant due to an insufficient number of teeth to support the requested code. Therefore, we decided that the Plan does not have to pre-approve pulpal debridement (D3221) for tooth #10 and periodontal scaling and root planing for 4 or more teeth per quadrant (D4341) for the upper left quadrant.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0999 and A0425) provided on September 4, 2020.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because these services were emergent and you were told they would be covered. The Plan denied your request. The Plan says payment is not allowed for these services because proof of payment is needed for claims reconsideration.
The Plan must follow Medicare rules. Medicare does not cover this service, so the Plan rules apply in this case. The Plan rules state that you must submit proof of payment for reimbursement of these services. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Specifically, the record does not include a proof of payment of the services rendered. This is needed in order to process reimbursement from the Plan. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0999 and A0425) provided on September 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency care provided from January 8, 2020, through March 13, 2020, from outside the United States.
You asked the Plan to pay for the services. You say that you went to the Philippines for leisure and had joint pain. You state you have had this joint pain in the past and received care in the Philippines for this pain. The Plan denied your request. The Plan says there is no medical documentation or records to indicate you received any care from an emergency facility for an emergent need. The Plan states received multiple injections and outpatient care for this pain, and you were not treated emergently for a life-threatening condition and you were not emergently admitted to a hospital for inpatient care.
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 non-emergency care provided from January 8, 2020, through March 13, 2020, from outside the United States.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport provided to the enrollee on July 25, 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 Medicare criteria.

We reviewed the 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. In the original review our physician reviewer commented that there was difficulty in establishing how stable or able the enrollee was to transport himself based on the records provided. This comment was not included in the original correspondence. In review of the records a second time, we find this to be a true statement, in that the records provided are insufficient to show that transport by means other than an ambulance would have been a danger to the enrollee's condition. In addition, the enrollee having used drugs and alcohol may have impaired his own ability to drive but did not constitute and emergent need for ambulance transport. 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 July 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922) and drugs or medicaments dispensed in the office for home use (D9630).

You asked the Plan to pre-approve the placement of a hemostatic agent and drugs dispensed in the office for home use. You say that the services are required for your tooth extraction, but you cannot afford the cost. The Plan denied your request. The Plan says these services are not covered under your 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 placement of intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922) and drugs or medicaments dispensed in the office for home use (D9630).