Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for genetic testing. We decided that the Plan does not have to pay for MTHFR testing.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan says that these tests are not covered by Medicare under the circumstances.
We decided that the Plan has to pay for psychotropic testing (81479).
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 follows these rules.
This testing was ordered by an in-network provider. The file does not show that the plan provided notice that psychotropic testing would not be covered. Under Medicare rules, this means psychotropic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for psychotropic testing.
We also decided that the Plan does not have to pay for MTHFR testing (81291).
The Plan follows Medicare rules. Medicare rules state that MTHFR testing has no clinical utility in any clinical scenario and is not covered.
Although this testing was ordered by an in-network provider, plan-directed care does not apply to coverage of this testing because MTHFR testing is excluded from Medicare coverage and is therefore never covered by the Plan. Therefore, we decided that the Plan does not have to pay for MTHFR testing.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular testing provided on December 18, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing, except the basic lipid panel.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. We looked at the file and the rules. The test at issue in this appeal was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular testing provided on December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share amount for the periodontal maintenance
(D4910) provided on January 21, 2021.
You asked the Plan to waive the cost share amount for the dental service. You say that you were given 2
different amounts, $53 and $64. You also say that you should not owe either amount. The Plan denied your
request. The Plan says there is a 50% coinsurance for Class 2 Basic Services. The Plan also says that
periodontal maintenance is listed as a Class 2 Basic Service.
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 and periodontal maintenance is listed as
a covered service, there is a 50% coinsurance for this service. The record shows that the allowed amount for
this service is $130 and you are responsible for $65 (50% of $130). This is a contractual obligation you agreed
to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to waive
the cost share amount for the periodontal maintenance (D4910) provided on January 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that clinical information provided supports the need for SNF care. The Plan denied your request. The Plan says there is no documentation supporting that the services required cannot be provided at the current inpatient rehabilitation facility (IRF).

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical records provided do not show documentation supporting the enrollee's need for skilled nursing services. The medical records do show that the enrollee has a need for skilled therapy services. However, these skilled therapy services are not required on a daily basis. The enrollee does not require the services on an inpatient basis, only in a SNF setting. Continued care in the inpatient rehabilitation facility is appropriate until the enrollee is stable to transfer to 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on February 10, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that you would have had the scans done on the same day if you had known that you would owe multiple copayments. 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 $200 copayment for diagnostic radiology services. You have been asked to pay a $200 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies 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 a CT scan provided on February 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy with a biopsy provided by a participating provider on January 20, 2021.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you think that this is being billed incorrectly. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for outpatient surgery. You have been asked to pay a $200 copayment for an outpatient surgery. The correct copayment has been applied to the services that were provided. An outpatient surgery falls within the outpatient surgery 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 a diagnostic colonoscopy with a biopsy provided by a participating provider on January 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for lab services provided to the enrollee and billed under code 87631.
You asked the Plan to pay for code 87631. You say that this service should be paid. The Plan paid all of the codes on this claim with exception of code 87631 stating the Medicare billing criteria were not met. Maximus overturned the Plans denial stating when this testing is performed in urgent care, the emergency room or a hospital, the test is covered. The Plan requested a reopen and stated this sample was taken from the enrollee at a residential skilled nursing facility and not in an urgent care, emergent care, or active treatment facility.
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. The codes billed must meet the required criteria. The lab order shows the sample was a swab test taken from the enrollee by the physician during a residential skilled nursing facility visit. The claim was not billed with a place of service code that allows billing for code 87631. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee and billed under code 87631.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and acupuncture provided by an out-of-network provider on March 2, 2021.
You asked the Plan to pay for the office visit and acupuncture. You say that you went to the approved provider but did not seek treatment due to COVID. You say that you were not informed the referral was expired and the member responsibility should be dismissed. The Plan denied your request. The Plan says a physician referral was not obtained.
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. The records show the previous authorization was expired and the new authorization was not yet active. Therefore, we decided that the Plan does not have to pay for the office visit and acupuncture provided by an out-of-network provider on March 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.
You asked the Plan to pre-approve Aranesp. You say that Aranesp will reduce the number of times the patient has to leave home each month. The Plan denied your request. The Plan says that requirements for coverage are not 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 Aranesp. Our reviewer says that Aranesp is not medically reasonable and necessary for the enrollee. National guidelines for the initiation of epoetin alpha, such as Aranesp, require that the hemoglobin be less than 10 and the ferritin be greater than or equal to 100. This patient's hemoglobin was above 10 and his ferritin was 25. Our physician reviewer found that the enrollee's condition does not meet criteria for Aranesp. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care rendered on March 23,
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 payment is included in the global surgical package.
The Plan must follow Medicare rules. The rules say that pre- and post-operative services are included in
payment of the global surgical package.
We looked at the file and Medicare rules. Payment for procedure code 99309 (subsequent nursing facility care)
is included in the global surgical package for procedure 11044 (debridement of skin and subcutaneous tissue)
billed on the same date. 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 subsequent
nursing facility care rendered on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the resin-based fillings provided for teeth #3, #13 and #14 on January 20, 2021.

You asked the Plan to waive the cost-share for the resin fillings. You say that you previously had amalgam fillings, but they were negatively affecting your mental health. The Plan denied your request. The Plan says that composite restorations on posterior teeth are not a benefit of the dental plan. Generally, it is not necessary to have a white filling on a back tooth where it is less likely to be seen. The Plan will pay the full cost of an equivalent amalgam (silver) filling, but you are responsible for the difference in cost between the customary amalgam filling and the resin.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay the difference in cost between an amalgam filling and a resin filling if you have a resin filling provided for a posterior tooth.

You have been asked to pay $159 for three resin-based fillings. The provider billed the Plan a total of $838.95 for all three fillings. The maximum approved fee for the resin fillings is $525. The Plan's contract states that the Plan will only cover the cost of amalgam fillings for posterior teeth. The three teeth in question, #3, #13 and $14, are all posterior teeth. The cost for these same fillings, done in amalgam rather than resin, totals $366. The Plan has covered the allowed amount for the amalgams in full as you are required to pay a $0 co-payment on the covered cost for fillings; however, you are responsible for the difference in cost between the maximum approved fee for the resin fillings and the covered cost of the amalgam fillings. ($525 - $366 = $159). 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 cost-share for the resin-based fillings provided for teeth #3, #13 and #14 on January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an exercise bike purchased April 2, 2020.
You asked the Plan to apply your wellness flex benefit toward the purchase of an exercise bike. You say that the Plan should reimburse you for this claim. The Plan denied your request. The Plan says the wellness benefit did not qualify for this type of purchase in April of 2020. Maximus overturned the denial administratively for insufficient benefit information in the case file. The Plan requested a reopen and provided additional information for review.
The Plan is correct in this case. Medicare does not cover exercise equipment. The Plan offers a benefit that exceeds Medicare coverage. Therefore, the Plans benefit rules apply in this case. Per the Plan benefit chart, the application of the wellness benefit to physical fitness items was only allowed between October 1, 2020 and December 31, 2020. You purchased the equipment in April of 2020. This purchase does not qualify for this benefit. Therefore, we decided that the Plan does not have to pay for gym equipment or gym benefits purchased April 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal appliance, CPT code 21089.
You asked the Plan to pre-approve an occlusal appliance. You say that this device is medically necessary. The Plan denied your request. The Plan says this device is not covered by Medicare. Maximus overturned the Plans denial stating the device was medically reasonable and necessary. The Plan requested a reopen and stated the issue was not medical necessity but that this device is paid under a dental code and is not covered under the Medicare benefit.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not cover an occlusal appliance under the Medicare benefit as it is coded as a dental benefit. Medicare does not cover devices for the treatment of TMJ. Based on the medical records provided, this device is not covered under the Medicare benefit under any condition. Therefore, we decided that the Plan does not have to pre-approve an occlusal appliance, CPT code 21089.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the head/brain.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not show documentation of physical exam results that included a detailed
nervous system exam suggestive of central nervous system disease.
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 scan. Our reviewer says that the
requested scan is not medically reasonable or necessary. Our physician reviewer found while a baseline
neuroimaging study is generally performed in the evaluation of dementia/cognitive impairments (to rule out a
significant structural etiology). However, in this context, performance of MRI is the generally preferred
imaging modality for this purpose/indication (as it provides more clinically relevant information). In the
absence of medical records, it cannot be concluded that you otherwise have a contraindication to the
performance of MRI.
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 scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve CT scan of the head/brain.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay provided on January 19, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing is not medically necessary
The Plan follows Medicare rules. Medicare rules say that pharmacogenomics testing is covered for the indications established in the applicable LCD. 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 testing. Our reviewer says that the requested GeneSight Psychotropic Assay is not medically reasonable and necessary in this case. Our physician reviewer found that the medical record indicates the enrollee is stable on her current drug regimen, but the enrollee still wants to do the GeneSight testing. The provided medical record does not indicate that the requested test is necessary or the physician's decision-making process regarding safely administering or dosing the drug. The record does not indicate that the enrollee has failed the drugs for which the test is requested. The medical record does not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested services. The elements of the coverage rules are not satisfied. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic Assay provided on January 19, 2021.
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. You say that the records provided support the need for care in an LTACH. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee can safely receive the care needed in another setting.
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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 waive the co-payment for inpatient hospital care provided on December 1, 2020, to December 9, 2020.

You asked the Plan to waive the co-payment for inpatient hospital care. You say that you do not believe you owe this amount of money. The Plan denied your request. The Plan says the co-payment you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 co-payment per day, for days 1-5 of inpatient hospital care. The Plan contract also says that you pay $0 for days 6 and beyond, for inpatient hospital care.

You have been asked to pay a $250 co-payment per day for inpatient hospital care ($250 x 5 days = $1,250). The EOC confirms that $250 is the required co-payment for this service. 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 co-payment for inpatient hospital care provided on December 1, 2020, to December 9, 2020.