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

We decided that the Plan does not have to pre-approve four periodontal scalings and root planings (D4341 x4).

You asked the Plan to pre-approve the scalings and planings. You say that you need this service to be approved for coverage. The Plan denied your request. The Plan says you have already received this service in all 4 quadrants.

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, periodontal scaling and root planing (D4341) is limited to 1 per quadrant in 24 months. The record shows that you received periodontal scalings and root planings (D4341) on September 1, 2020, and your periodontal scaling and root planing (D4341) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve four periodontal scalings and root planings (D4341 x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation provided on December 22, 2020.

You asked the Plan to pay for the periodic oral evaluation. You say that you are allowed two exams per year and believe this exam should be covered. The Plan denied your request. The Plan says benefits for this service had been satisfied and the frequency limitation had been exceeded. The Plan also says that there were no calls made to the Plan to verify your benefits prior to the service being rendered.

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, periodic oral exam and emergency diagnostic exam share the same frequency and are limited to two procedures per calendar year. The record shows that you received a periodic oral exam on June 16, 2020, and an emergency diagnostic exam on August 19, 2020, and your exams benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation provided on December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to waive the copayment for hearing services provided on September 14, 2020.

You asked the Plan to waive the copayment for hearing services. You say that you feel that you should only
owe a $30 copayment. The Plan denied your request. The Plan says that 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. Your
contract with the Plan says that enrollees must pay a $0 copayment for hearing services.

The Plan says you must pay a $147.48 copayment for hearing services. Based on the Plan contract, however,
you cannot be asked to pay more than a $0 copayment for hearing services. Therefore, we decided that the Plan
has to waive the copayment for hearing services provided on September 14, 2020.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor supplies coded as A9276 and A9277.

You asked the Plan to pre-approve codes A9276 and A9277. You say that these supplies are medically necessary. The Plan denied your request. The Plan says the supplies requested are being provided out of network and are not covered by Medicare for use with equipment coded as K0554. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that codes A9276 and A9277 are not used to bill for supplies used with a therapeutic continuous glucose monitor (CGM) coded as K0554. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitor supplies coded as Codes A9276 andA9277 are not used to bill for supplies used with code K0554.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the Superion procedure is experimental. More research is needed to show safety and efficacy of the device. 

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 the insertion of a Superion interspinous stabilization device (22869).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve daratumumab.

You asked the Plan to pre-approve daratumumab. You say that the medication is necessary. The Plan denied 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 Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 daratumumab. Our reviewer says that the medication is not medically necessary. Our physician reviewer found in this case, the Medicare compendia do not contain any positive citations for the requested drug and noted indication. The requested drug is not medically necessary or reasonable as defined my Medicare rules. The coverage criteria 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 daratumumab have not been met. Therefore, we decided that the Plan does not have to pre-approve daratumumab.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 and 80307 provided on August 3, 2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code G0483 and 80307 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 and 80307 provided on August 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the prosthetic eye provided to the enrollee on July 15, 2019.

You asked the Plan to pay for the prosthetic eye. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. 

The services you asked the Plan to pay for are considered vision services or eyewear. Prosthetic eyes are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the prosthetic eye provided to the enrollee on July 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to preapprove for the acute inpatient hospital care.

You asked the Plan to preapprove for acute inpatient hospital care. You say that the claim should be approved. The Plan denied your request. The Plan says the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 preapprove for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the provided documentation does not indicate that the enrollee has unstable or uncontrolled medical conditions.  The record does not indicate that the treating physician had a reasonable expectation of a length of stay spanning 2 or more midnights.  The elements of the coverage rule are not satisfied.  The requested service is not 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to preapprove for the acute inpatient hospital care.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for DecisionDx Melanoma testing provided on October 20, 2020.

You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare and was ordered by the enrollee's treating physician to inform treatment decisions. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing does not meet the Medicare criteria for coverage.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for DecisionDx Melanoma testing provided on October 20, 2020.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre sensors.

You asked the Plan to pre-approve Freestyle Libre sensors. You say that this is medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for coverage.

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 documentation indicates that you do not perform blood glucose testing at least four times per day and use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre sensors.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health nursing services.

You asked the Plan to pre-approve the home health care services. You say that you have had 2 back surgeries and have cancer. You say that you are going through chemotherapy. You say that it is difficult for you to carry things and lift. You say that you need help in your house. You also say that you take medication that makes you tired and you are unable to function properly. The Plan denied your request. The Plan says they reached out to your doctor who advised that home care was not discussed at your last appointment. The Plan says that you do not have a skilled need that would require a skilled nurse that the provider is aware of and will not be ordering the service you requested.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health care services have not been met. Additionally, there is no record of a physician order for home health care, nor any plan of care that was established by a physician. The provided medical records do not contain any information regarding home health services or justifying the need for home health services. Therefore, we decided that the Plan does not have to pre-approve home health nursing services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from December 15, 2020, to December 18, 2020.

You asked the Plan to pay for the SNF care. The Plan denied your request. The Plan says the enrollee no longer required SNF 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 pay for the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that there were no identifiable skilled nursing service needs. There were no identifiable skilled therapy service needs. The enrollee did not require skilled nursing or therapy services on a daily basis. The enrollee did not meet severity of illness or intensity of service criteria for 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 the SNF care have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from December 15, 2020, to December 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for lab work provided by a participating provider on October 23, 2020.

You asked the Plan to waive the deductible for lab work. You say that this was part of your annual wellness exam. The Plan denied your request. The Plan says the correct deductible amount has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $300 deductible for outpatient diagnostic tests/in-network.

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests/in-network. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible for outpatient diagnostic tests/in-network. This cost sharing is a contractual obligation that had not been met at the time lab work was received on October 23, 2020. The total amount you are being asked to pay is $137.20. When additional services are provided during an annual wellness exam, additional cost sharing amounts can be applied. Therefore, we decided that the Plan does not have to waive the deductible for lab work provided by a participating provider on October 23, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a partial upper denture (D5213) and a lower partial denture (D5214).
You asked the Plan to pre-approve a partial upper denture and a lower partial denture. You say that you would like these services covered. The Plan denied your request. The Plan says that you exceeded the maximum count allowed per period.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a partial upper denture and a lower partial denture have been met. Specifically, the EOC states that one procedure is covered every 5 years. The EOC does not disclose that only one upper denture code is covered once every 5 years or that one lower denture code is covered once every 5 years. Therefore, we decided that the Plan has to pre-approve a partial upper denture (D5213) and a lower partial denture (D5214).
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Alimta (Pemetrexed) and Carboplatin injection for the enrollee.

You asked the Plan to pre-approve Alimta (Pemetrexed) and Carboplatin injection. You say that this drug is medically necessary. The Plan denied your request. The Plan says The Plan states 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 Alimta (Pemetrexed) and Carboplatin injection. The Maximus Physician Reviewer determined that the drug combination met criteria. The Plan argues that there is no established evidence to support the use of Alimta with carboplatin for adenocarcinoma of the parotid gland. Our Medical Director has concluded that based on the medial records, the Plan is correct in this case. The use of Alimta (Pemetrexed) and Carboplatin is not FDA-approved for the treatment of metastatic adenocarcinoma of the parotid gland, and its use in this setting is not supported by one of the major drug compendia, or by clinical research in a CMS-approved medical journal. 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 Alimta (Pemetrexed) and Carboplatin injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an Alimta (Pemetrexed) and Carboplatin injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental occlusal guard (D9945) for teeth grinding.

You asked the Plan to pre-approve the occlusal guard. You say that this mouth guard is medically necessary. The Plan denied your request. The Plan says the requested dental guard is not covered by Medicare or by the Plan's supplemental dental benefit.

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-approve a dental occlusal guard (D9945) for teeth grinding.