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

We decided that the Plan does not have to pre-approve a Group 2 heavy duty power wheelchair (K0825).
You asked the Plan to pre-approve a heavy duty power wheelchair. You say that you would prefer the requested item. The Plan denied your request. The Plan says rules for a heavy duty power wheelchair have not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a heavy duty power wheelchair. Our reviewer says that the requested item is not medically necessary. Our physician reviewer found that, based on the medical records provided, there is no documentation that you have a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. Records indicate that you are unhappy with your present power
wheelchair as it does not have adequate power to go up hills. Maneuvering up hills is not consistent with
"mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary
locations within the home." Furthermore, there is no documentation that your mobility deficit cannot be helped
by the use of a walker, cane, or manual wheelchair.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a heavy duty power wheelchair have not been met. Therefore, we decided that
the Plan does not have to pre-approve a Group 2 heavy duty power wheelchair (K0825).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital bed provided on October 12, 2020, by a non-participating provider.

You asked the Plan to pay for a hospital bed. You say that the item was medically necessary. The Plan denied your request. The Plan says authorization must be received, and an in-network provider must be utilized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for a hospital bed provided on October 12, 2020, by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe ocrelizumab injection and intravenous infusion provided on September 10, 2020.You asked the Plan to waive the coinsurance forthe ocrelizumab injection and intravenous infusion. You say that due to COVID you were sent to the hospital for the medication. You say that you have never paid that much for the medication before.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B prescription drugs.You have been asked to pay $4,250, which is less than the standard 20% coinsurancefor the ocrelizumab injection and intravenous infusionbecause you met your maximum out-of-pocket. The ocrelizumab injection and intravenous infusion 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 coinsurance forthe ocrelizumab injection and intravenous infusion provided on September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete maxillary denture (D5110) and complete
mandibular denture (D5120) provided on January 6, 2021.
You asked the Plan to pay more for the complete maxillary denture and complete mandibular denture. You say
that you believe the Plan should pay the $1,260 in full for the dentures because the enrollee could not get them
last year. You also say that the enrollee's maximum benefit last year was $3,000. The Plan denied your request.
The Plan says the enrollee is responsible for a $195 copay for each denture, and went over the annual
maximum by $260.
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 enrollee is responsible for a $195
copayment for each of the complete maxillary denture (D5110) and complete mandibular denture (D5120). The
Plan also offers a max allowance amount of $1,000 per year for supplemental comprehensive dental services.
The contract says that the enrollee is responsible for all cost over and above the allowance amount. The record
shows that the enrollee met their annual maximum benefit while processing this claim for the January 6, 2021,
date of service and the enrollee's annual maximum benefit has been exhausted. Therefore, we decided that the
Plan does not have to pay more for the complete maxillary denture (D5110) and complete mandibular denture
(D5120) provided on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for acupuncture provided from October 14, 2020, to November 9, 2020.
You asked the Plan to pay for this treatment. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says these services were not rendered by a physician as is required by the Plan contract. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract language. The Plan states that the servicing provider is an out-of-network acupuncturist. The Evidence of Coverage clearly states that acupuncture is covered for relief of pain or the in place of anesthesia for a surgical or dental procedure and must be provided by a physician licensed to perform the service.
The Plan states there are no other claims showing that the acupuncture service was performed for a surgical or dental procedure. The Plan states you indicated these services were appealed in 2019 and the services were allowed. The Plan has confirmed a previous appeal was overturned for date of service October 23, 2019 as a one-time exception. A letter was mailed to you on February 12, 2020 which advised that this was a one-time exception for coverage. Additionally, the Plans records show you were advised in a recorded phone call on January 15, 2020 that acupuncture was covered for relief of pain or "In lieu" of other anesthesia for a surgical or dental procedure and that your provider should submit for prior authorization if they felt the services should be covered.
We find the Plan is correct in this case. The Plan must follow Medicare rules. The rules say that for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for chronic low back pain meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. The Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. The Plan contract clearly states acupuncture services must be provided by a licensed physician. The provider in question is an acupuncturist but not a licensed physician. The Plan has demonstrated that you were given a onetime exception a previous service and that you were made aware of the contract requirements prior to further services being rendered. Therefore, we decided that the Plan does not have to pay for acupuncture provided from October 14, 2020, to November 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on September 11, 2020.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says prior authorization was requested and denied before this service was provided. Maximus overturned the Plans denial due to being ordered by a Plan provider. The Plan requested a reopen and stated that the Plan provider and the out of network lab were aware prior to the service being rendered that prior authorization had been denied by the Plan and that is testing was done for screening purposes.
The Plan is correct in this case. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The records provided do not clearly show how the results of this testing would impact any type of future treatment. The Plan had previously denied this service before it was rendered. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on September 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first
intraoral periapical x-ray (D0220), and bitewing x-ray (D0270) provided on February 15, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and
bitewing x-ray. You say that before receiving the service, you called to make sure the check-up would be
covered. You also say that you were told the check up and certain x-rays would be covered. The Plan denied
your request. The Plan says these 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.
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), first intraoral periapical x-ray (D0220), and bitewing x-ray
(D0270) provided on February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve dialysis services. You say that you would like approval for these services so the member can receive the highest level of care. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 dialysis services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network thoracic oncologist.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.
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 a referral to an out-of-network thoracic oncologist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 20, 2020.

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 claim was incorrectly billed.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on October 20, 2020.
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 stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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, with a history of cirrhosis, was admitted after developing hypotension on dialysis and having hypercapnic respiratory failure and metabolic encephalopathy. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 25, 2021.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says all care with non-contracted providers require prior authorization. The Plan will only cover non-contracted providers if the service is for an emergency and if it is medically necessary to go out of network. No information was presented to indicate that this is for emergency care or that the requested provider delivers care uniquely required for your condition.
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 physician's services provided on January 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion Device Placement Surgery for the
enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that experimental and investigational procedures are not covered by
Medicare.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Current evidence
based medical guideline and peer reviewed literature do not fully support the spinal decompression device
procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peerreviewed
outcome studies to support the use of this device for this enrollee's medical condition. Our physician
reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Vertiflex Superion Device Placement Surgery for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection of sclerosant; multiple incompetent veins
(other than telangiectasia), same leg (CPT code 36471), for the enrollee.
You asked the Plan to pre-approve the injection. You say that the enrollee has failed conservative treatment
including gradient compression stockings, leg elevation, exercise, and pain medication. The Plan denied your
request. The Plan says the enrollee's record does not show that the enrollee has tried the other conservative
treatments of weight loss, exercise, and leg evaluation.
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 injection. Our physician reviewer
found the record indicates that the enrollee has saphenous reflux. The enrollee has been approved for bilateral
ablation and phlebectomy. This has not yet occurred. The elements of the coverage rule are not satisfied. The
requested service cannot be recommended 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 injection have
not been met. Therefore, we decided that the Plan does not have to pre-approve injection of sclerosant; multiple
incompetent veins (other than telangiectasia), same leg (CPT code 36471), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that acute rehab will provide intensive therapy to support the patient's goal of returning to baseline function. The Plan denied your request. The Plan says that the member's care needs can be met in the skilled nursing facility setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for ventricular tachycardia, and vertigo. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the computed tomography (CT) scan of face (70486) provided February 16, 2021.
You asked the Plan to waive the coinsurance for the CT scan of face. You say that you would like this coinsurance waived. The Plan denied your request. The Plan says the coinsurance has processed correctly in this case.
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 diagnostic radiology services. You have been asked to pay a total cost share of $32.79 for the CT scan of face ($163.97 Medicare-allowed amount x 20% coinsurance). This service falls within the diagnostic radiology 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 coinsurance for the computed tomography (CT) scan of face (70486) provided February 16, 2021.