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

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and the unspecified preventive procedure, by report (D1999) received January 27, 2021.

You asked the Plan to pay for the dental services. You say that the frequency limitation for the requested services was not exhausted. The Plan denied your request. The Plan says there are no specialist dentists in the dental provider network.

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 covered under this benefit when received from a specialist dentist. The dental provider in this case is a specialist dentist. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) and the unspecified preventive procedure, by report (D1999) received January 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model without calibrated gradient pressure (CPT code E0651) and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667 x2), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 DME. Our physician reviewer found the review indicates that there was no documentation regarding clinical findings and no information regarding a four (4) week trial with compression stockings, etc. The review has determined that the medical records provided did not meet the requirements listed in the LCD for Medicare 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 the DME have not been met. Therefore, we decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model without calibrated gradient pressure (CPT code E0651) and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667 x2), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on November 7, 2020.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.
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 G0483 is drug test(s), definitive, utilizing (1) drug
identification methods able to identify individual drugs and distinguish between structural isomers (but not
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type,
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g.,
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drugspecific
calibration and matrix-matched quality control material (e.g., to control for instrument variations and
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or
more drug class(es), including metabolite(s) if performed.
We find that CPT code G0483 is not supported in the medical record. Specifically, the records show that only
21 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of drug
testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483)
provided on November 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunization provided on December 30, 2020.
You asked the Plan to pay for the immunization. You say that the copay is incorrect, and you were told at your
visit the tetanus shot would be at no additional cost. The Plan denied your request. The Plan says they will
reduce the copayment, but the vaccine is not covered under your Medicare Part B Immunization benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization.
The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the immunization.
Therefore, we decided that the Plan does not have to pay for the immunization provided on December 30,
2020.
Benefits for the immunization 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removal of torus palatinus (D7472) and two removals of torus mandibularis (D7473 x2).
You asked the Plan to pre-approve the removal of torus palatinus and removals of torus mandibularis. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered under your benefit 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-approve a removal of torus palatinus (D7472) and two removals of torus mandibularis (D7473 x2).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427) received February 3, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were not anticipating this bill and you cannot afford the copayment at this time. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $300 copayment for Ambulance Services. You have been asked to pay a $300 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427) received February 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from January 25, 2021, to January 31, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you had to have a second surgery due to faulty hardware and feel that you should not be responsible for the copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $492 copayment for days 1-4 for inpatient hospital care. You had an inpatient hospital stay from January 25, 2021, to January 31, 2021. Therefore, you are responsible
to pay a $492 copayment for days 1-4 (January 25, 2021, to January 28, 2021). $492 (copayment) x 4 (inpatient days) = $1,968. You have been asked to pay the total copayment amount of $1,968 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 inpatient hospital stay provided from January 25, 2021, to January 31, 2021.
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ground mileage (A0425) and non-emergent ambulance transport (A0428) provided on January 20, 2021 by an OON provider.
You asked the Plan to pay for the ground mileage and ambulance transport. You say that any other means of transportation would have been harmful to the enrollee's health and condition. The Plan denied your request. The Plan says that the certification or authorization is denied after review from the medical management department.
The Plan must follow Medicare rules. Medicare rules say that plans must pay for ambulance services when an emergency exists or when other means of transport would endanger the patient's health. An emergency is defined as when a prudent layperson would believe that without immediate medical attention there would be serious jeopardy to his or her health. We looked at your request, the file and Medicare rules. Based on this information we have decided that Medicare coverage criteria have been met. Specifically, the record clearly indicates that the member was experiencing dyspnea. A prudent layperson would believe that without immediate medical attention there would be serious jeopardy to his or her health. This is a case involving an emergency. Based on this information, we decided that Medicare rules for coverage of the ground mileage and ambulance transport have been met. Therefore, we decided that the Plan has to pay for the ground mileage (A0425) and non-emergent ambulance transport (A0428) provided on January 20, 2021 by an OON provider.
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 PWC, group 3 heavy duty, multiple power option,
sling/solid seat/back, patient weight capacity 301 to 450 pounds (CPT code K0862) and the accessories (CPT
code(s): E2363, E1007, E2300, E0955, E1028, E1012, E2377, E2311, E2313, and E2608).
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied
your request. The Plan says you do not have a qualifying diagnosis causing mobility limitation for which the
power wheelchair is medically needed.
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 DME. Our physician reviewer
found you do not have an appropriate diagnosis for a group 3 PWC. Furthermore, the documentation doesn't
indicate that your needs cannot be met with a group 2 PWC. There is no indication that you are at high risk for
skin breakdown.
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 DME have not been met. Therefore, we decided that the Plan does not have
to pre-approve PWC, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity
301 to 450 pounds (CPT code K0862) and the accessories (CPT code(s): E2363, E1007, E2300, E0955, E1028,
E1012, E2377, E2311, E2313, and E2608).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, thorax, diagnostic; without contrast material (CPT
code 71250).
You asked the Plan to pre-approve the CT scan. You say that the service is necessary. The Plan denied your
request. The Plan says the records do not show the size of the nodule.
The Plan must follow Medicare rules. Medicare rules say that CT 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 pre-approve the CT scan. Our
physician reviewer found the tiny nodules on CT from 2019 were not described in an actual size large enough
to justify regular annual surveillance with CT. Also, the most recent clinical assessment did not describe the
patient as having new or worsening acute signs or symptoms to justify CT. Therefore, this request for such will
be considered not medically necessary based on the provided documentation. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT, thorax,
diagnostic; without contrast material (CPT code 71250).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 29, 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 services are not separately payable.
The Plan must follow Medicare rules. The rules say that Medicare does not pay any provider or supplier other than the hospital for services furnished to a beneficiary who is an inpatient.
We looked at the file and Medicare rules. The file shows that the billed services were performed while the enrollee was under inpatient status. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 29, 2020.
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.

You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.

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. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
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.

You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.

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. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at an alternate 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan rendered on March 10, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.
We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid primary
diagnosis code. Based on this information, we decided that Medicare rules for coverage of these services have
not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography
(PET) scan rendered on March 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transportation (A0428, A0425) received November 27, 2020.You asked the Plan to waive the copayment forthe ambulance transportation. You say that you were told coverage for the ambulance transportation was approved.The Plan denied your request. The Plan says coverage of the ambulance transportation was approved, and your cost share for approved Ambulance Services is a $200 copayment.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (suchas copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for Ambulance Services. You have been asked to pay a $200 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance 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 forthe ambulance transportation (A0428, A0425) received November 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Egoscue therapy purchased on April 30, 2020.
You asked the Plan to pay for Egoscue therapy. You say that this service is beneficial for you and similar to other fitness classes. You say this should be covered by the health and wellness allowance. The Plan denied your request. The Plan says this is not a covered service under your health and wellness benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Under the health and wellness benefit, the Plan can cover membership in a qualified health club or fitness facility, covered instructional fitness classes, participation in wellness programs such as Matter of Balance, Chronic Disease self-management, diabetes workshop, Healthy Eating for Successful Living, Healthy IDEAS, Powerful Tools for Caregivers, Arthritis Foundation Exercise, Enhance Wellness, Fit For Your Life, AAA Senior Driving, memory fitness activities, acupuncture, and/or covered nutritional counseling sessions with a licensed nutritional counselor or registered dietician.
The Plan's rules for coverage of gym benefits have not been met because Egoscue therapy is not listed as a covered service under this benefit. Therefore, we decided that the Plan does not have to pay for Egoscue therapy purchased on April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network care.

You asked the Plan to pre-approve out-of-network care. You say that your daughter's health is declining, and it would not be this way if the network doctors would be consistent with each other. You say that referral to the clinic needs to be approved. The Plan denied your request. The Plan says the necessary care is available in-network.

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 out-of-network care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle brace (L1902), provided on March 24, 2020.
You asked the Plan to pay for an ankle brace. You say that you became frustrated and ordered an ankle brace
online because the Plan failed to fulfill their obligation and order you a brace, which forced you to order the
brace on your own. The Plan denied your request. The Plan says DME must be provided through a Medicare
certified provider. Per the Medicare certified DME suppliers from the Medicare Supplier Directory, this
provider is not listed to be acceptable provider for you. However, the plan found several Medicare supply
stores less than 15 miles from your zip code.
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 an ankle brace (L1902), provided on March 24,
2020.