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

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for genetic testing. You say that the ordering physician determined that this testing was medically necessary. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not covered, the provider is out-of-network with the Plan, and prior authorization was denied by the Plan.

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 denied prior authorization for this testing. 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 the medical services provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).

You asked the Plan to pre-approve Euflexxa (J7323). You say that you need this drug because it is difficult for you to walk or do daily activities without pain. The Plan denied your request. The Plan says you have not first tried and had a contraindication or intolerance to Synvisc/Synvisc One.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Euflexxa (J7323). Our reviewer says that based on the medical records provided the patient has not tried and failed the required drug(s). Our physician reviewer found based on the medical records provided there is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the patient.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa (J7323) have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care dressings provided on September 24, 2020.
You asked the Plan to pay for the services provided. You say that the enrollee had no control over which physician would be assigned. The Plan denied your request. The Plan says the items were related to the cauterization performed on the same date of service.
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 the gauze and alginate wound cover at issue in this appeal area bundled codes, and are covered as incident to the approved cauterization procedure. 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 pay for the wound care dressings provided on September 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lumigan Sol 0.01%.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested medication is denied as a benefit exclusion.

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 Lumigan Sol 0.01%.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a mandibular partial denture provided on July 29, 2020.
You asked the Plan to pay for denture. You say that you were given invalid provider information each time you called the Plan customer service, which forced you to receive service from this provider. The Plan denied your request. The Plan says the denial of payment for this denture is correct, because this is not covered by the Plan. The Plan also says that they have overturned the denial of payment for the other dental services you appealed, so this denial is only for the mandibular partial denture with dental code D5226.
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 pay for a mandibular partial denture provided on July 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 26, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the cost of the lab tests should be covered in full. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
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 to provide the lab services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 26, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tremfya 100mg/ml injections.
You asked the Plan to pre-approve Tremfya. You say that this medication is medically necessary. The Plan denied your request. The Plan says Tremfya is not eligible for coverage under the Part B medical benefit.
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 Tremfya 100mg/ml injections.
Benefits for Tremfya 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an aide to assist with cleaning the house.
You asked the Plan to pre-approve home cleaning assistance. You say that you have difficulty using stairs and have no energy. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because these services are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that home health aide services may be covered only if the enrollee has home health skilled care needs. Medicare rules say that custodial care services are not covered. We looked at the file and Medicare rules. Assistance with cleaning is a custodial care service. Based on this information, we decided that Medicare rules for coverage of home cleaning assistance have not been met. Therefore, we decided that the Plan does not have to pre-approve an aide to assist with cleaning the house.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an observation stay provided on October 31, 2020.
You asked the Plan to waive the copayment for an observation stay. You say that you feel that you were released too early from a previous stay. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $125 copayment for outpatient hospital observation. You have been asked to pay a $125 copayment for an observation stay. An observation stay falls within the outpatient hospital observation 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 an observation stay provided on October 31, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the out-of-network provider.
You asked the Plan to pre-approve the physical therapy. The Plan denied your request. The Plan says the services are not emergent or urgent and are available within the network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's current health status does not indicate a need for this bed.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 bed. Our reviewer says that the requested bed is not medically reasonable or necessary. Our physician reviewer found your condition has not failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is 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 the bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pin retention.

You asked the Plan to pay for the pin retention. You say that no one from the insurance company told the provider they were using an outdated form until calls were made. The Plan denied your request. The Plan says this service is not covered under the 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 pay for the pin retention.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3320) core buildup, including pins when required (D2950) and porcelain crown (D2740).

You asked the Plan to pre-approve the dental services. You say that the plan's denial states the services requested is not a covered benefit, but in fact, it is covered under comprehensive services. You are owed dental coverage up to $500. The Plan denied your request. The Plan says the services are not covered under the plan benefits.

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 health plan contract says that any services not listed are not covered.

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 endodontic therapy (D3320) core buildup, including pins when required (D2950) and porcelain crown (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 14 Day Sensor (CPT code K0553).

You asked the Plan to pre-approve the item. You say that you have severe reactive hypoglycemia. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The Medicare criteria for the requested item has not been met. You do not have diabetes, you are testing three (3) times per day, and you are not using insulin. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14 Day Sensor (CPT code K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397).

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the services were medically necessary. The Plan denied your request. The Plan says there is no evidence prescribing physician ever saw member.

The Plan follows Medicare rules. Medicare rules say that for the knee orthosis and suspension to be covered, Medicare criteria as cited in the Rules section must be 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 the knee orthosis and suspension sleeve. Our reviewer says that the items were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a power wheelchair and accessories.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that as the base code for the requested wheelchair is not reasonable or necessary, none of the requested accessories can be approved.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The file shows that the plan had access to medical records and information that was not provided to MAXIMUS in the submitted case file. The plan has not substantiated their denial. Therefore, we decided that the Plan has to pre-approve a power wheelchair and accessories.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Repatha for the enrollee.
Benefits for this drug 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L2397, L1833) provided September 11, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were medically necessary. The Plan denied your request. The Plan says there is no evidence prescribing physician examined the enrollee.
The Plan follows Medicare rules. Medicare rules say that for a knee orthosis, knee instability must be documented by examination of the beneficiary and objective description of joint laxity. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the knee orthosis and suspension sleeve. Our reviewer says that the items were not medically necessary and reasonable. Our physician reviewer found there is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L2397, L1833) provided September 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on September 2, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a telehealth visit and you should not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $30 copayment for specialist visits. You have been asked to pay a $30 copayment for a specialist visit. A 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 a specialist visit provided on September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for medical supplies provided by a participating provider on October 28, 2020.
You asked the Plan to waive the coinsurance for medical supplies. You say that you were told that this would cost $4. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for durable medical equipment. The enrollee has been asked to pay a 20% coinsurance of the allowed amount for medical supplies. The total allowed amount is $85.20. The total amount you are being asked to pay is $17.04 ($85.20 x 20% = $17.04). Medical supplies fall within the durable medical equipment benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for medical supplies provided by a participating provider on October 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a transvaginal ultrasound (76830) and an ultrasound of the pelvis (76856).

You asked the Plan to waive the copayment for the ultrasounds. The Plan denied your request. The Plan says this copayment 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 $160 copayment for radiological diagnostic services.

You have been asked to pay a $277.15 copayment for the two ultrasounds, which is less than the total $320 ($160 x 2 = $320) copayment allowed by the Plan. An ultrasound falls within the radiological diagnostic 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 a transvaginal ultrasound (76830) and an ultrasound of the pelvis (76856).