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

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on February 16, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you would like these services to be reconsidered for coverage. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. The Plan also says that you were not enrolled in the Dental Platinum Rider on this date of service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on February 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on January 26, 2021.

You asked the Plan to waive the copayment for an EGD. You say that you were told that you would 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 $225 copayment for outpatient surgery, including services provided at hospital outpatient facilities.

The medical records show that you received an EGD at an outpatient hospital facility on January 26, 2021. An EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $225 copayment. 

You have been asked to pay a $225 copayment for an EGD. An EGD falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 EGD provided on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-ray (D0270), the pulp vitality test (D0460),
and the cone beam CT capture with interpretation (D0364) provided on December 2, 2020.

You asked the Plan to pay for the bitewing x-ray, pulp vitality test, and cone beam CT. You say that you were
told these services would be covered. You also say that you need help paying this bill. The Plan denied your
request. The Plan says 1 bitewing x-ray is covered per year. The Plan says that the frequency limit has been
exceeded. The Plan says that pulp vitality test is not listed as a covered service. The Plan says that cone beam
CT capture with interpretation is not listed as a covered service either.

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 bitewing x-ray is listed as covered,
the frequency limit has been exceeded. The record shows that the Plan paid for a bitewing x-ray that you
received on May 11, 2020. Additionally, pulp vitality test and cone beam CT capture with interpretation are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
bitewing x-ray (D0270), the pulp vitality test (D0460), and the cone beam CT capture with interpretation
(D0364) provided on December 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for colonoscopy, flexible, with biopsy, single or multiple (45385) provided May 29, 2020.

You asked the Plan to waive the copayment for the colonoscopy. You say that you are being billed in the amount of $1340 for this claim and date of service. The claim is currently in collections. The Plan denied your request. The Plan says this claim was processed with the correct copayment applied per the Evidence of Coverage.

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 $200 copayment for each Medicare covered ambulatory surgery center visit.

You have been asked to pay $200 copayment for the colonoscopy. The colonoscopy falls within the 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 colonoscopy, flexible, with biopsy, single or multiple (45385) provided May 29, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve scaling and root planing (D4341) for all 4 quadrants.

You asked the Plan to pre-approve the dental services. You say that your gums are bleeding and swollen. You say that the dentist cannot proceed with regular cleaning without deep cleaning. The Plan denied your request. The Plan says that the scaling and root planing for all 4 quadrants is not medically necessary.

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 Plan covers the dental services when the services are medically necessary and reasonable. 

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 dental services. Our reviewer says that the scaling and root planing is medically necessary. Our physician reviewer found On the basis of the documentation presented, the periodontal scaling and root planing (D4341) meet the criteria for coverage. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to pre-approve scaling and root planing (D4341) for all 4 quadrants.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient hospital observation services, 2 diagnostic procedures, and a specialist physician visit provided on January 7 to January 9, 2021.

You asked the Plan to waive the copayments for outpatient hospital observation services, diagnostic procedures, and a specialist physician visit. You say that the Department of Veterans Affairs (VA) instructed you to go to the local emergency room as you were in an emergency situation. The Plan denied your request. The Plan says the correct copayments were 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 $225 copayment for outpatient hospital observation services; a $35 copayment for each specialist visit, including outpatient clinic visits; and a $5 copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility). 

You have been asked to pay a $225 copayment for outpatient hospital observation services; a $5 copayment for each one of 2 diagnostic procedures, and a $35 copayment for a specialist physician visit. Outpatient hospital observation services, diagnostic procedures, and a specialist physician visit when provided within an outpatient hospital setting fall within the "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 copayments for outpatient hospital observation services, 2 diagnostic procedures, and a specialist physician visit provided on January 7 to January 9, 2021.

Your complaint about being referred by the VA to a non-VA hospital to is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the biopsy rendered on January 8, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 11102 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the biopsy rendered on January 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast biopsy provided on May 13, 2019.

You asked the Plan to waive the copayment for a breast biopsy. You say that you did not receive the services in a hospital facility and disagree with the charges. 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 $345 copayment for outpatient surgery, including services provided at hospital outpatient facilities.

The record shows that you received a breast biopsy at an outpatient hospital facility on May 13, 2019. Therefore, you are responsible to pay the $345 copayment.

You have been asked to pay a $345 copayment for a breast biopsy. A breast biopsy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 breast biopsy provided on May 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the wheelchair rental provided on January
12, 2021.

You asked the Plan to waive the coinsurance for the wheelchair rental. You say that it took 2 months for the
provider to come and get the wheelchair so you should not be responsible for the coinsurance. The Plan denied
your request. The Plan says you were charged this coinsurance 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 20%
coinsurance for Durable Medical Equipment.

You have been asked to pay 20% coinsurance for the wheelchair rental. the wheelchair rental falls within the Durable Medical Equipment 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 wheelchair rental provided on January 12, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve treatment with Zarxio (Q5101).

You asked the Plan to pre-approve Zarxio. You say that the requested treatment is necessary for the enrollee's care as the chemotherapeutic regimen has been delayed due to neutropenia. The Plan denied your request. The Plan says that the requested treatment is not reasonable and necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Zarxio. Our reviewer says that the requested treatment is medically necessary. Our physician reviewer found that the enrollee is treated with Folfiri and Avastin. Folfiri is deemed an intermediate risk for febrile neutropenia. With the enrollee's comorbid conditions, the use of Zarxio for the enrollee's condition is supported by the National Comprehensive Cancer Network (NCCN) drug compendium.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zarxio have been met. Therefore, we decided that the Plan has to pre-approve treatment with Zarxio (Q5101).

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the phlebotomy services described by code 99195 provided on January 7, 2021.

You asked the Plan to waive the copayment for the phlebotomy services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received phlebotomy services on the date of service at issue in this appeal in an outpatient hospital facility. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $100 copayment for Outpatient hospital services.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received phlebotomy services on January 7, 2021. You have been asked to pay a $98.97 copayment for the phlebotomy services, which is less than the contracted $100 copayment amount. The phlebotomy services fall within the 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 the phlebotomy services described by code 99195 provided on January 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure (CPAP) device for the enrollee.
You asked the Plan to pre-approve continued use of a continuous positive airway pressure (CPAP) device for the enrollee. You say that this equipment is medically necessary for the enrollee. 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 a CPAP machine. The Maximus Physician Reviewer determined the equipment was medically necessary. The Plan requested a reopen and argues the Medicare guidelines are clear that the coverage criteria must be met. The Plan specifically notes that "Beneficiaries who fail the initial 12-week trial are eligible to re-qualify for a PAP device but must have both: In-person clinical re-evaluation by the treating physician to determine the etiology of the failure to respond to PAP therapy; and repeat sleep study in a facility-based setting (Type 1 study). This may be a repeat diagnostic, titration or split-night study." The medical records show the enrollee is a 70-year-old woman with obstructive sleep apnea. CPAP was prescribed in 2020. On January 22, 2021 it is documented that the enrollee had not been using her equipment nightly based on the machine data and adherence was inadequate. Our Medical Director has concluded that the Plan is correct in this case. The documentation does not support that the coverage criteria for continued CPAP usage were met in this case. To be eligible to re-qualify for this device the enrollee would need both an in-person clinical re-evaluation by the treating physician and a repeat
sleep study in a facility-based setting (Type 1 study). 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 continued use of a continuous positive airway pressure (CPAP) device for the enrollee have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure (CPAP) device for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on September 27, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was enrolled in Hospice when the services were provided.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on September 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your continued needs can be met through a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of an intensive insulin regimen (three or more injections).
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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that you inject insulin twice a day. The elements of the coverage rule are not satisfied. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the chemotherapy drugs provided on January 4, 2021.
You asked the Plan to waive the cost share for the services provided. You say that you never had to pay this much for your infusions. The Plan denied your request. The Plan says the cost share applied appropriately.
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 total cost for Medicare Part B prescription drugs. You have been asked to pay 20% of the total cost for the services provided. The services fall within the 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 cost share for the chemotherapy drugs provided on January 4, 2021.