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

We decided that the Plan does not have to pay for bone replacement graft for ridge preservation (D7953), 
extraction, erupted tooth or exposed root (D7140) provided August 11, 2020. 
 
You asked the Plan to pay for the bone replacement graft and tooth extraction. You say that you were not aware 
that the provider had opted out of Medicare. The Plan denied your request. The Plan says the provider has 
opted out of Medicare and therefore the services 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. The Plan covers the bone 
replacement graft and tooth extraction when they are provided by a licensed dental provider who has not opted 
out of Original Medicare. 
 
We looked at the file and Medicare rules. The request is for services which were provided by a dentist who has 
opted out Medicare. Based on this information, we decided that the Plan's rules for coverage of the bone 
replacement graft and tooth extraction have not been met. Therefore, we decided that the Plan does not have to 
pay for bone replacement graft for ridge preservation (D7953), extraction, erupted tooth or exposed root 
(D7140) provided August 11, 2020.  
 
Your complaint about potentially not receiving the Plan's Annual Notice of Change 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of inpatient 
skilled nursing facility 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 care. Our reviewer says that 
inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the 
documentation supports that you are expected to benefit from skilled therapy services; however, it is not 
demonstrated that these services are needed on a daily basis. Additionally, as a practical matter, you do not 
require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the $10 copayment charged for lab services.

You asked the Plan to waive this copayment. You say that you had a physical and this was part of that visit so there should be no charge. The Plan denied your request. The Plan says lab services are not included in the blanket cost of the physical.

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 $10 copayment for lab services. The Plan is correct, lab services are not included with the claim submitted for an annual physical. Lab services are a separate and distinct service and require copayment. 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 $10 copayment charged for lab services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of cervical spine.

You asked the Plan to pre-approve magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material (72141). You say that the enrollee is in extreme pain. The Plan denied your request. The Plan says that there is no record of a face-to-face or 6-week trial of provider directed treatment.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material (72141). Our reviewer says that the service is medically necessary. Our physician reviewer found based on the records provided for review, the member does have some signs or symptoms that potentially localize to the cervical spine. In this setting/context, it can be determined that the requested imaging study would otherwise be reasonable and necessary in nature. In as much this would meet Medicare criteria for coverage.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material (72141) have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of cervical spine.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiological diagnostic services provided 
by a participating provider on November 13, 2020. 
 
You asked the Plan to waive the copayment for radiological diagnostic services. You say that last time you had 
this you did not have a copayment. The Plan denied your request. The Plan says the correct copayment amount 
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 $100 
copayment for outpatient diagnostic tests/radiological diagnostic services.  
 
You have been asked to pay $65.70 which is less than your copayment amount of $100 for radiological 
diagnostic services. The correct copayment has been applied to the services that were provided. Radiological 
diagnostic services fall within the outpatient diagnostic tests/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 radiological diagnostic services provided by a participating 
provider on November 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.
You asked the Plan to pre-approve Ilumya. The Plan denied your request. The Plan says the step therapy requirements have not been met.
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 Ilumya. Our reviewer says that Ilumya is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of drugs Inflectra or Remicade, and Stelara before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ipratropium.
You asked the Plan to pre-approve Ipratropium. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Part B 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 Ipratropium.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy for the enrollee.
You asked the Plan to pre-approve this service. 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 hyperbaric oxygen (HBO) therapy. The Maximus Physician Reviewer determined that the enrollee had a wound that had been present for an extended period and had failed all therapies. It was determined that HBO therapy was indicated due to the needed treatment of documented wounds and associated infection. The Plan argues that there is no documentation of a diagnosis or clinical situation which meets the criteria for HBO treatment under the NCD. The medical records show the enrollee is a 59-year-old woman with a history of Sjogren's syndrome, lupus, cancer, vasculitis, pancreatitis, and hypertension. The enrollee presented with non-healing wounds on the dorsum of her right hand and right 4th finger. The enrollee was treated with surgical debridement. The enrollee has been treated serially at a wound care clinic. Our Medical Director has concluded that the plan is correct in this case. The documentation does not support that the coverage criteria for HBOT as established by NCD 20.29 have been met in this case. The enrollee does not have a diagnosis for which HBOT is 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to leave the hospital and could possibly be exposed to other things while staying at the hospital. You say that the enrollee is qualified to go to a long-term facility, and he is also on oxygen and he has had multiple failed weaning attempts. The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about your condition the enrollee does not meet all the requirements.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted to the current acute care hospital with acute respiratory failure related to COVID-19 pneumonia. He was treated with oxygen, NIPPV, BiPAP, bronchodilators, steroids, diuresis, and Remdesivir. The recent notes show that steroids are being tapered and BiPAP setting is FIO2 60% with peak airway pressure of 16. The enrollee appears to be improving and more stable and only requires short-term additional acute care services that can safely be received at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Therefore, this request for LTACH will be considered not medically necessary at this time. Transfer to a lower level of care may be considered soon when treatment has completed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a non-
participating provider on September 25, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. 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). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for outpatient diagnostic tests/out-of-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an ultrasound. The total allowed 
amount is $27.07. The total amount you are being asked to pay is $5.41 ($27.07 x 20% = $5.41). The correct 
coinsurance has been applied to the services that were provided. An ultrasound falls within the outpatient 
diagnostic tests/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 an 
ultrasound provided by a non-participating provider on September 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided September 30, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not ordered by the treating physician. 
 
The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating 
the beneficiary are not reasonable and necessary. 
 
We looked at the file and Medicare rules. Plan documents note that the plan contacted the enrollee, who 
confirmed that the ordering physician was not a physician that was treating him. Based on this information, we 
decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that 
the Plan does not have to pay for genetic testing (81479) provided September 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CGM and sensors (CPT code(s): A79277 and (A9276).

You asked the Plan to pre-approve the supplies. You say that you need this equipment to keep your blood sugar normal. 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 clinical information provided does not indicate that you require blood glucose monitoring at least 4 times a day, that you use insulin with several (three or more) daily injections or a Medicare-covered continuous subcutaneous insulin infusion pump. Medical records, state that you currently monitor your blood glucose twice a day as well as perform injections twice a day. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve CGM and sensors (CPT code(s): A79277 and (A9276).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 3, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says members 
must receive care from an in-network provider. In most cases, care members receive from an out-of-network 
provider will not be covered.  If the member needs medical care that Medicare requires our Plan to cover and 
the providers in our network cannot provide this care, the member can get this care from an out-of-network 
provider. Authorization should be obtained from the Plan prior to seeking care. Providers are responsible to 
check eligibility prior to seeing members. 
 
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 
physician's services. 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 physician's services provided on August 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (CPT 99358) provided to the enrollee 
from October 11, 2020 to October 17, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation provided does not indicate that face-to-face services were performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99358 is "prolonged evaluation and management before 
and/or after direct patient care; first hour." 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the medical 
records provided do not include documentation to validate that face-to-face services were performed for the 
enrollee, therefore these services cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for physician services (CPT 99358) provided to the enrollee from October 11, 2020 to October 17, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation - per quadrant (CPT code D4921 x4), core buildup, including any pins when required for tooth #3 and #4 (D2950), and crown - porcelain/ceramic for tooth #3 (D2740).

You asked the Plan to pre-approve the dental services. You say that there is no logic to approving deep cleaning without approving irrigation. You state one crown was approved, but not the adjustment of the crown. You also state, food gets on your crown and creates cavities. The Plan denied your request. The Plan says you exhausted your benefit for D2740 and codes D4921 and D2950 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.

Review of the records indicate you were previously approved for D2740, for tooth # 4. Therefore, you exhausted this benefit. Your 2021 Dental Benefit Schedule states, "crown - up to one (1) per calendar year. Benefit limited to codes: D2740 / D2750." Furthermore, your dental plan does not cover codes D4921 and D2950. Therefore, we decided that the Plan does not have to pre-approve gingival irrigation - per quadrant (CPT code D4921 x4), core buildup, including any pins when required for tooth #3 and #4 (D2950), and crown - porcelain/ceramic for tooth #3 (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided October 
26, 2020. 
 
You asked the Plan to pay for the panoramic x-rays. You say that the provider should not have provided you a 
non-covered service. The Plan denied your request. The Plan says the service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
panoramic radiographic image (D0330) provided October 26, 2020.  
 
Your complaint about not being told by the provider prior to receiving the service that it is not covered 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services of a HH/hospice aide in HH or hospice settings 
provided from August 31, 2020, to September 4, 2020. 
 
You asked the Plan to pay for the services of a HH/hospice aide in HH or hospice settings. The Plan denied 
your request. The Plan says these services were rendered by a provider who is not under contract with the 
Health Plan, and is not certified for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services, a provider or supplier must be enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services of HH/hospice aide in HH or hospice settings have not been met. This provider is not 
part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for 
the services of a HH/hospice aide in HH or hospice settings provided from August 31, 2020, to September 4, 
2020.