Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for medical services provided on July 19 - August 13, 2019.
You asked the Plan to pay for the medical services provided. You say that you have paid out-of-pocket for an accident and would like to be reimbursed. The Plan denied your request. The Plan says that this is your secondary insurance and they have not obtained Explanation of Benefits (EOBs) from this insurance carrier for the services in dispute. The Plan says that they have reached out to your health plan to obtain EOBs, but that they have been unable to provide the documents without the enrollee's authorization.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan has not provided evidence of having billed the primary insurer, directed the provider to send the bill to the primary insurer, or paid for the services and billed the primary insurance for reimbursement. Therefore, we decided that the Plan has to pay for medical services provided on July 19 - August 13, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the OncotypeDx testing rendered to the enrollee on March 6, 2019.
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 that the testing was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that OncotypeDx testing is covered when specific criteria are 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 pay for these services. Our reviewer says that the testing was medically necessary. Our physician reviewer found the enrollee has a diagnosis of unspecified type of carcinoma in situ of unspecified breast. The Surgical Pathology Report documents a diagnosis of ductal carcinoma in situ, nuclear grade 2-3, measuring approximately 3 cm in the greatest dimension. The documentation supports that the enrollee meets all of the criteria for coverage listed in the Medicare rules for the OncotypeDx testing. The testing was reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pay for the OncotypeDx testing rendered to the enrollee on March 6, 2019.
The Plan references LCD L33586 in their determination; however, this LCD is not binding for the testing at issue and was not used in the MAXIMUS determination.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from January 20, 2020 through January 21, 2020 provided by an in-network provider.You asked the Plan to waive the copayment for inpatient hospital care. You say that you went to the hospital and was seen for an emergency and thought all this was covered and not a $700.00 copay. She was unaware would have a copay for the admission so does not believe she should have to pay The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from January 20, 2020 through January 21, 2020 provided by an in-network provider. You are asked to pay a $700 copayment for the in-network inpatient hospital care. 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 inpatient hospital care from January 20, 2020 through January 21, 2020 provided by an in-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan has to pre-approve a crown (D2750) for tooth # 13.
You asked the Plan to pre-approve the dental service. You say that the crown is needed since the root canal was approved. You also say that signs of decay are present as a root canal was approved for the same tooth. The Plan denied your request. The Plan says that the x-rays do not show a cavity under the present dental crown.
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 service is medically necessary. Our physician reviewer found that the existing crown on tooth number 13 is clearly ill fitting, with a very over contoured mesial aspect and possibly open mesial margin making for very poor environment for the gums and a lack of sufficient closure of the margin to prevent recurrent decay. The provider has not given a clear indication that there is decay at the margins, however the very poor shape and fit of the crown noted on radiograph would dictate that the original crown is significantly ill fitting. The crown is so ill fitting, as seen on radiograph, that it would be considered medically necessary to replace that crown to prevent future marginal decay and chronic periodontal inflammation. The reviewer found that the requested service would be medically 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 been met. Therefore, we decided that the Plan has to pre-approve a crown (D2750) for tooth # 13.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on
November 13, 2019.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that the summary of benefits
does not specify the type of x-rays that are covered. The Plan denied your request. The Plan says this service
was already rendered on May 8, 2019, exhausting your x-rays 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, complete intraoral series is limited to
once every 60 months. The record shows that you received this service on May 8, 2019 and your complete
intraoral series x-ray benefit is now exhausted. Therefore, we decided that the Plan does not have to pay for the
complete series of intraoral x-rays provided on November 13, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Prolia injection (J0897).You asked the Plan to pre-approve a Prolia injection. You say that the enrollee has osteoporosis and her kidney function has been declining and Prolia is more appropriate for her.The Plan denied your request. The Plan says the enrollee does not meet the medical necessity guidelines and the criteria has not been met Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Prolia injection. Our reviewer says that this enrollee does not meet the criteria for the requested Prolia injection. Our physician reviewer found the enrollee has not tried and failed Zoledronic acid and the documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. The medical records in the case file do not support a diagnosis of renal impairment and there is no documentation of the enrollee's creatinine clearance.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 Prolia injection have not been met.Therefore, we decided that the Plan does not have to pre-approve a Prolia injection (J0897)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a gym membership with requested gym from April 17, 2019 to September 17, 2019.

You asked the Plan to reimburse you for the gym membership. The Plan denied your request. The Plan says the reimbursement submission was received past the quarterly submission deadline of July 30, 2019.

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.

The Plan's rules for coverage of gym benefits have not been met because the reimbursement submission was received past the quarterly submission deadline. Therefore, we decided that the Plan does not have to reimburse you for a gym membership with requested gym from April 17, 2019 to September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea walk-in shower.You asked the Plan to pre-approvea walk-in shower. You say that it is dangerous for you to step in and out of your bathtub.The Plan denied your request. The Plan says that this is excluded from coverage by Medicare.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea walk-in shower.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair, bathtub wall rail, and incontinence supplies.You asked the Plan to pre-approve a shower chair, bathtub wall rail, and incontinence supplies. You say that you have difficulty walking and need these supplies.The Plan denied your request. The Plan says these items are not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable and grab bars are self-help items. While a shower chair, bathtub wall rails and incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approve a shower chair, bathtub wall rail, and incontinence supplies.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on November 8, 2019.You asked the Plan to pay forthe ambulance services. You say that you requested to be taken to your preferred hospital and the ambulance responders refused so you do not feel you should have to pay for the emergency services. The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 8, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.You requested transportation to a facility that was not the nearest appropriate facility and then refused transport. Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on November 8, 2019
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 18, 2019 to the enrollee by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.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 has network providers available who can provide 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 forthe medical services provided on November 18, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services
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 services that charge greater than $500 requires prior authorization.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan requires prior authorization for services that charge over $500. 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 the medical services
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee (G0151 physical therapy and G0156 home health aide) for dates of service April 11, 2019 through April 19, 2019.
You asked the Plan to pay for home health services provided to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says the Medical Director determined that based on the medical records the enrollee's diagnosis is diabetes mellitus. The information provided indicates the enrollee was hospitalized with aspiration pneumonia and increased weakness with orders received for home health care due to homebound status and requirement for continued skilled care in the home. The Plan states the records provided do not support the services billed. The original claim and the corrected claim both have invalid Treatment Auth codes (TAC).
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT codes. In this case, the claims submitted lack the appropriate TAC code. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee (G0151 physical therapy and G0156 home health aide) for dates of service April 11, 2019 through April 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) and suspension sleeve L2397) provided October 2, 2019.You asked the Plan to pay for the orthoses. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says the services are not supported in the medical records received.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 pay for the orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided medical records do not contain the required documentation to support the medical necessity for the bilateral knee orthoses and suspension sleeves as defined in the Local Coverage Determination.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 orthoses have not been met.Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833) and suspension sleeve L2397) provided October 2, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forneedle electromyography studies (51785) provided on September 24, 2018.You asked the Plan to pay forthe needle electromyography studies. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the diagnosis code submitted is not appropriate for the service billed.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 51785 is not supported in the record. Specifically, per Local Coverage Article: Billing and Coding: Anorectal Manometry, Anal Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters (A56530),the diagnosis code submitted does not support the service billed. Based on this information, we decided that Medicare rules for coverage of the needle electromyography studies have not been met.Therefore, we decided that the Plan does not have to pay forneedle electromyography studies (51785) provided on September 24, 2018.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approveProlia. You say that the enrollee has contraindications to the required drugs.The Plan denied your request. The Plan says step therapy requirements have not been met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Prolia. Our reviewer says that the criteria for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial of one oral bisphosphonate and (Reclast) zoledronic acid before they will approve the requested drug. The documentation does not support that the enrollee has tried Reclast (Zoledronic acid), or that this drug would likely be less effective or have adverse effects for the enrollee in this case. COPD/asthma is not listed as a contraindication or a precaution for the use of Zoledronic acid.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygenator assembly and operation services (CPT 99190) provided to the enrollee on November 19, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
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 99190 is "Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour." We find that CPT code 99190 is not supported in the medical record. Specifically, payment for this code is included in the payment to the facility. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for oxygenator assembly and operation services (CPT 99190) provided to the enrollee on November 19, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve office visits. You say that you would like approval for function medicine consult. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. Please contact the plan for a list of in-network providers available. 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 office visits to be provided by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ER visit provided on October 24, 2019.You asked the Plan to waive the copayment foran ER visit. You say that you thought that the ER visit would be covered.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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an ER visit. An ER visit falls within the emergency 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 foran ER visit provided on October 24, 2019.