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

We decided that the Plan does not have to pre-approvetwo core buildups, including any pins when required (D2950 x2) and two pontics (D6245 x2).You asked the Plan to pre-approvethe core buildups and pontics. You say that you need this bridge.The Plan denied your request. The Plan says these services are not covered by your dental plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvetwocore buildups, including any pins when required (D2950 x2) and two pontics (D6245 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device from an out of network (OON) provider.You asked the Plan to pre-approvethe OON pneumatic compression device. You say that the in-network provider the enrollee is being referred to does not carry Flexitouch. You say that the specific Flexitouch pneumatic compression device is medically necessary for the enrollee.The Plan denied your request. The Plan says there are pneumatic compression devices available in-network.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. 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 OON pneumatic compression device. Our reviewer says that the criteria for OON coverage have not been met. Our physician reviewer found the Plan's denial medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through referral for an in-network pneumatic compression device. There is nothing unique about the enrollee's condition that would make it medically necessary for her to see the requested OON provider. The Plan has shown that they have in-network providers who meet the Standards of Care required for treatment of the enrollee's condition.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 OON pneumatic compression device have not been met.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device from an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe interpretation of the CT scan of the soft tissues of the neck provided on August 24, 2020.You asked the Planto pay forthe CT scan interpretation. You say that this is not a duplicate as multiple studies were performed on the date of service.The Plandenied your request. The Plansaysno evidence was submitted to support that more than two CT scans of the neck were performed.The Plan must follow Medicare rules. Medicare rules say that exact duplicate claims should be denied. The rules also require providers to submit sufficient information to support that payment is due.The Plan has provided evidence showing that payment wasmade for an interpretation of a CT scan of the neck. An exact duplicate claim was denied. On appeal, the provider submitted two identical copies of the same imaging report, both signed at the same time. This does not support that more than one imaging interpretation was provided. As such, the denial of payment is supported.Therefore, we decided that the Plandoes not haveto pay forthe interpretation of the CT scan of the soft tissues of the neck provided on August 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omnipod Mis.

You asked the Plan to pre-approve Omnipod Mis. You say that this is necessary to treat the enrollee's diabetes. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

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 Omnipod Mis. 

Benefits for Omnipod Mis may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plandenied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as describedabove.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. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forhearing aids purchased on October 20, 2020 from an out-of-network (OON) provider.You asked the Plan to pay forhearing aids. You say that you believed the Plan's hearing aid vendor would provide you with poor service.The Plan denied your request. The Plan says you must use the Plan's hearing aid vendor to receive coverage for hearing aids.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only they are purchased from the Plan's hearing aid vendor.We looked at the file and the Plan's rules. The file indicates that you purchased hearing aids from an OON provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met.Therefore, we decided that the Plan does not have to pay forhearing aids purchased on October 20, 2020 from an out-of-network (OON) provider.Your complaint about potentially not receiving information regarding the Plan's hearing aid vendor 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant (D6010) for tooth # 30. 
 
You asked the Plan to pre-approve the dental service. You say that you need the implant. The Plan denied your 
request. The Plan says the implant is not medically necessary. The Plan also says that your provider did not 
provide reason of medical necessity for the implant for tooth # 30. 
 
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 
service 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 service. Our reviewer says 
that the implant is not medically necessary. Our physician reviewer found the documentation provided shows 
that tooth # 30 is the only tooth that is missing. The reviewer found that the enrollee appears to have adequate 
masticatory function since all other teeth are present and in occlusal contact. Therefore, the reviewer found that 
the requested implant is not medically reasonable or necessary. 
 
 
 
 
 
 
 
 
 
 
 
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 service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an implant (D6010) for tooth # 30.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that this is the appropriate treatment for 
this enrollee. The Plan denied your request. The Plan says there is a lack of studies supporting the necessity of 
this surgery. 
 
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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the spacer is not appropriate for this patient. There is no documented spinal 
instability. Hardware is not needed. Also, the spacer remains experimental. More research is needed to show 
safety and efficacy. 
 
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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a Superion interspinous spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental extraction services provided on September 2, 2020.You asked the Plan to pay forthe dental procedure. You say that you were not informed by this provider that he had opted out of Medicare. You feel that you should have been informed which dental providers accept your plan because you were just told you needed to submit receipts for reimbursement.The Plan denied your request. The Plan says reimbursement cannot be made for these services because the provider has opted out of Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay forthe dental extraction services provided on September 2, 2020
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. The Plan denied your request. The Plan says the enrollee has not yet completed the full course in the hospital.

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 physician reviewer found that the enrollee was admitted to the current acute care hospital with septic shock and small bowel obstruction requiring surgery. She was treated with ileostomy and wound care including Wound VAC. Sodium is low, she still has leukocytosis, and she requires additional antibiotics and close monitoring.  The enrollee appears to be more stable, but requires additional short-term acute care services, which can safely be administered at the current facility. She does not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee needs care in an IRF in order to return to maximum function.The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rulesto 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. Our physician reviewer found the enrolleedoes not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive coinsurance forMedicare Part B prescription drugs provided from January 3, 2020, through January 31, 2020.You asked the Plan to waive coinsurance forMedicare Part B prescription drugs. You say that the final figure should only be a $50 copayment.The Plan denied your request. The Plan says the correct coinsurance was applied 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 20% coinsurance for Medicare Part B Prescription Drugs.You have been asked to pay 20% coinsurance for Medicare B Prescription Drugs. The services at issue 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 coinsurance forMedicare Part B prescription drugs provided from January 3, 2020, through January 31, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on March 9, 2020 and billed under code 81401.

You asked the Plan to pay for this service. You say that this testing should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial for provider directed care. The Plan requested a reopen stating this was a billing issue and not a coverage issue. The Plan states that the claim should have been billed under code 81479 with the approved DEX-Z-Code.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the claim cannot be paid as billed due to the omission of  the codes required for this type of testing. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on March 9, 2020 and billed under code 81401
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to providePositron Emission Tomographywith Computed Tomography.You asked the Plan to providea PET scan with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815). You say that the enrollee needs a PET scan for further evaluation and treatments.The Plan denied your request. The Plan says the medical record documents no evidence of recurrence.The Plan must follow Medicare rules. Medicare rules say that PET scans 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 provide Positron emission tomography (PET) with concurrently acquired computed tomography(CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815). Our reviewer says that the service is not medically necessary. Our physician reviewer found deny surveillance PET CT per NCD 220.6.17. In addition,enrollee has had more than threePET scans. Imaging with CTscans can be considered if deemed medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815) have not been met.Therefore, we decided that the Plan does not have to providePositron Emission Tomography.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the provision of Intensity Modulated Radiation Therapy 
(IMRT) with image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve the provision of IMRT with IGRT. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 provision of IMRT with IGRT. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found for this case, there is no letter of appeal, supporting citations or plausible 
explanation of why more standard vaginal brachytherapy was not offered to this enrollee. In the absence of a 
supporting rationale, pelvic radiotherapy is not considered to be furnished in accordance with accepted 
standards of care following from NCCN guidelines and ASTRO evidence-based guidelines. 
 
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 provision of IMRT with IGRT have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the provision of Intensity Modulated Radiation Therapy (IMRT) 
with image-guided radiation therapy (IGRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetwo endosteal implants (D6010 x2).You asked the Plan to pre-approvethe endosteal implants. The Plan denied your request. The Plan says this 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 pre-approvetwo endosteal implants (D6010 x2).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computed tomography (CT) scan to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve an OON CT scan. You say that you need a CT scan from the provider you 
have been seeing. The Plan denied your request. The Plan says this is available in network. The Plan has also 
indicated that your provider has confirmed there is no issue with obtaining the CT scan from an in-network 
provided. 
 
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 
the computed tomography (CT) scan to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea fluid circulating cold pad with pump.You asked the Plan to pre-approvethe requested device. You say that the device is needed to bring the swelling and pain down after surgery.The Plan denied your request. The Plan says the device is a non-covered benefit.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. a fluid circulating cold pad with pump (E0218) will be denied as not reasonable and necessary.Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approvea fluid circulating cold pad with pump.