Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 14,
2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that this item was medically necessary for
the enrollee. The Plan denied your request. The Plan says this patient did not receive video or telephonic visit
by the ordering physician in order to warrant the codes billed
The Plan follows Medicare rules. Medicare rules say that the spinal orthosis is subject to the criteria listed in
the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the lumbar-sacral orthosis. Our reviewer
says that the requested item was not medically reasonable and necessary. Our physician reviewer found an
appropriate history and a physical examination of the back would reasonably be required to adequately assess
whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support
that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is
insufficient documentation of an appropriate evaluation and a credible physical examination of the back.
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 lumbar-sacral orthosis have not been met. Therefore, we decided that the
Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311,
E2313, E2377) for the enrollee.
You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The
Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the additional accessories. Our reviewer
says that the requested additional accessories are not considered medically reasonable and necessary in this
case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of
proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control,
etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to
operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate
control devices), other electronic devices (e.g., control of an augmentative speech device or computer through
the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities
with the ability to feed himself indicates that the patient can control any power options through their own
individual switches.
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 additional accessories have not been met. Therefore, we decided that the
Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the
enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120), the cleaning (D1110), the bitewing x-rays (D0274), and the unspecified preventive service (D1999) provided on July 1, 2020.
You asked the Plan to reimburse you for the dental services. You say that you received dental services in 2019 from this provider that were reimbursed. You say that the dental services you received in 2020 were not reimbursed. You also say that you should be reimbursed for these services. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services that you receive from a provider who has opted out of Medicare.
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 the services are listed as covered, dental services that you receive from a provider who has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120), the cleaning (D1110), the bitewing x-rays (D0274), and the unspecified preventive service (D1999) provided on July 1, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve physical therapy. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health aide services (S9122).

You asked the Plan to pay for home health aide services. You say that this should be covered. The Plan denied your request. The Plan says these services are not documented.

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 S9122 is not supported in the medical record. Specifically, no documentation of home health services being performed has been submitted. Furthermore, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pay for home health aide services (S9122).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued rental of a low air loss mattress
You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of ulcers at the trunk or pelvis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the mattress. Our reviewer says that the requested mattress i not medically reasonable or necessary. Our physician reviewer found he documentation does not reveal evidence of multiple stage II pressure ulcers located on the trunk or pelvis, large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis, or evidence of a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis.
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 mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve continued rental of a low air loss mattress.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic apheresis for the enrollee.
You asked the Plan to pre-approve this treatment. You say that this treatment 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 that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for therapeutic apheresis. The Maximus Physician Reviewer determined that apheresis is an accepted therapy for this condition. The Plan argues that apheresis is not a covered treatment for familial hypercholesterolemia. The medical records show the enrollee has familial hypercholesterolemia, carotid atherosclerosis, arteriosclerosis of the abdominal aorta, coronary atherosclerosis, peripheral vascular disease, family history of premature coronary heart disease, and tobacco dependence syndrome. Our Medical Director has concluded that the Plan is correct in this case. The documentation is insufficient to demonstrate that apheresis is medically reasonable and necessary for the enrollee in this case. The Medicare National Coverage Determination (110.14) does not provide coverage criteria for the use of therapeutic apheresis in the treatment of hypercholesterolemia.
No study has demonstrated significantly improved survival with LDL apheresis. The evidence for clinical benefit through regular apheresis comes from observational data. Adequate, randomized, controlled trials are lacking. 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 this treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic apheresis; with extracorporeal immunoadsorption, selective adsorption or selective filtration and plasma reinfusion (CPT Code 36516)for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating provider.

You asked the Plan to waive the copayment for an office visit. You say that you went for your annual wellness exam. You say that you should not have a copayment for this. The Plan denied your request. The Plan says the correct copayment 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). Your contract with the Plan clearly says that you must pay a $10 copayment for physician/practitioner services/PCP office visit.

You have been asked to pay a $10 copayment for an office visit. Evidence was provided that showed that additional concerns were address during your annual wellness exam; therefore, an additional copayment has been applied correctly. An office visit falls within the physician/practitioner services/PCP office visit 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 office visit provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care services provided by a participating provider on August 12, 2020.
You asked the Plan to waive the copayment for vision care services. You say that you do not agree with this. You say that you have never had a copayment for this before. The Plan denied your request. The Plan says the correct copayment has been applied to the services that were 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 $10 copayment for vision care/in-network. You have been asked to pay a $10 copayment for vision care services. The correct copayment has been applied to the services that were provided. Vision care services fall within the vision care/in-network 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 vision care services provided by a participating provider on August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and repair of broken complete denture base (D5512) provided on August 20, 2020.
You asked the Plan to pay for the complete denture and repair of denture base. You say that you do not agree with the amount you were reimbursed and feel the Plan should be paying more for the services provided on August 20, 2020. The Plan denied your request. The Plan says a complete maxillary denture and the repair of the broken denture base are not covered by Medicare or by the Plan's supplemental dental benefit. Therefore, no reimbursement can be provided for these services as they are 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 pay for the complete maxillary denture (D5110) and repair of broken complete denture base (D5512) provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346) and the surgical removal of residual tooth roots (D7250 x 2) provided on June 2, 2020.
You asked the Plan to pay for the dental services. You say that these services should be covered. You say that you contacted the Plan prior to your appointment. You say that you were advised that the provider was in network. You also say that you received a bill for $578. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services that you receive out of network are not covered. The Plan also says that the services are not listed as 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, dental services that you receive out of network are not covered. Additionally, the services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346) and the surgical removal of residual tooth roots (D7250 x 2) provided on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on October 12, 2020.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 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 a domiciliary, rest home visit provided on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological services provided on October 16, 2020.
You asked the Plan to pay for ophthalmological services. You say that you had the exam for your eye infection
not for eyeglasses. The Plan denied your request. The Plan says eye refraction exams are not covered by
Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and
eyewear.
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we
decided that the Plan does not have to pay for the ophthalmological services provided on October 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and injections provided by an out-of-network provider.

You asked the Plan to pay for the office visit and injections. You say that the provider's office advised the insurance was accepted but the dermatologist was out-of-network. The Plan denied your request. The Plan says this provider is out of network and prior authorization was not requested.

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 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 the office visit and injections provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a participating provider on November 16, 2020.
You asked the Plan to waive the copayment for outpatient hospital services. You say that you went in for your annual exam. The Plan denied your request. The Plan says the correct copayment 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). Your contract with the Plan clearly says that you must pay a $20 copayment for outpatient hospital services/in-network/outpatient hospital services. You have been asked to pay a $20 copayment for outpatient hospital services. Outpatient hospital services fall within the outpatient hospital services/in-network/outpatient hospital 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 outpatient hospital services provided by a participating provider on November 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic services provided on April 30, 2019.
You asked the Plan to pay for diagnostic services. You say that this claim was filed within the timely limit. The
Plan denied your request. The Plan says the denial of payment for these services is correct, because this claim
was not submitted within the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for diagnostic services was not filed until July 30, 2020. This means that more
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that
the Plan does not have to pay for diagnostic services provided on April 30, 2019.
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 cannot stay in the current hospital. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct.

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 you do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. You are receiving appropriate care at the current acute care hospital. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition at this time. 

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive one of the copayments for ambulance services provided on November 9, 2020.
You asked the Plan to waive one of the copayments for the ambulance services. You say that on this date of service, you were first taken to the emergency room at one hospital, then transferred to another hospital. You believe that this should be considered one service and only one copayment should apply. The Plan denied your request. The Plan says you were charged two copayments 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 $250 copayment for each one-way trip for ambulance services. Records show that you had two one-way trips via ambulance on this date of service. You have been asked to pay a $250 copayment for each one-way trip for the ambulance services. 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 one of the copayments for ambulance services provided on November 9, 2020.