Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom orthoses (L1940, L2330, L2820). 
 
You asked the Plan to pre-approve the custom orthoses. You say that the braces are medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a custom orthosis is covered only when medically 
necessary and when a prefabricated brace cannot be properly fit. 
 
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 custom orthoses. Our reviewer says 
that the custom orthoses are not medically necessary. Our physician reviewer found there is no clinical rational 
for the requested custom brace. The clinical notes do not show that the member has tried and failed a 
prefabricated brace. 
 
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 custom orthoses have not been met. Therefore, we decided that the Plan 
does not have to pre-approve custom orthoses (L1940, L2330, L2820).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transport (A0428) and ground 
mileage (A0425) provided on March 14, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for non-emergent ambulance service and ground mileage. You say that the services 
rendered were medically necessary. The Plan denied your request. The Plan says prior authorization must be 
obtained for non-emergent services rendered by an out of network provider. 
 
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 for the non-emergent ambulance transport (A0428) 
and ground mileage (A0425) provided on March 14, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of fluoride (D1208), the filling for an anterior 
tooth (D2331 x 2), the filling for a posterior (D2392 x 3), the periodontal maintenance (D4910), and the 
gingival irrigation (D 4921 x 4) provided on June 24, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were advised you had a $1,000 allowance 
per year for dental services. You say that this has put a burden on you. You also say that you were given 
misinformation by the plan representative. The Plan denied your request. The Plan says there is an annual 
maximum allowance of $1,000 per year. The Plan says after the annual maximum is exhausted, any remaining 
charges are your responsibility. The Plan also says gingival irrigation is not listed as a covered 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 fluoride, fillings and periodontal 
maintenance are listed as covered services, the annual maximum benefit of $1,000 has been exceeded prior to 
the date of service in this appeal. The record shows that the Plan paid $116 towards services that you received 
on February 26, 2020 and $884 towards services that you received on February 27, 2020. Additionally, 
gingival irrigation is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the treatment of fluoride (D1208), the filling for an anterior tooth (D2331 x 2), the filling for a 
posterior (D2392 x 3), the periodontal maintenance (D4910), and the gingival irrigation (D 4921 x 4) provided 
on June 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous use of the CPAP. 
 
You asked the Plan to pre-approve continuous use of the CPAP. You say that you need the CPAP for quality 
sleep. The Plan denied your request. The Plan says the record shows you are not compliant. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The compliance report shows you are not using the CPAP 4 hours per 
night on 70% of nights during the month. Based on this information, we decided that Medicare rules for 
coverage of continuous use of the CPAP have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuous use of the CPAP.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on June 24, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you already paid a $150 copayment. 
The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for Medicare Part B prescription drugs/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $1,160.28. The total amount you are being asked to pay is $232.06 (1,160.28 x 20% = $232.06). An 
injection falls within the Medicare Part B prescription drugs/in-network 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 coinsurance for an injection provided by a participating provider on June 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided to the enrollee on October 
29, 2019. 
 
You asked the Plan to pay for the ambulance services. You say that this claim should be reprocessed. The Plan 
denied your request. The Plan says that with the information they have, they cannot determine whether the 
services are medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We looked at the file and Medicare rules. The record does not contain any medical records to confirm the 
medical necessity of these services. Based on this information, we decided that Medicare rules for coverage of 
the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the 
ambulance services provided to the enrollee on October 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically 
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
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 
that Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do 
not provide clinical services that are materially different than those of short-term acute care hospitals. In this 
case, ongoing care needs include respiratory support with oxygen supplementation, nebulizer treatments, 
intravenous nutrition, surveillance laboratory studies, and therapy services. The documentation does not 
support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. There are no required medical services identified that are 
available at the LTACH, that are not available at the current health care setting being offered by the health 
plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate 
for the diagnosis and condition of the enrollee at this time.  
 
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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs to your reclining chair.
You asked the Plan to pre-approve the reclining power wheelchair repair. You say that the repairs are necessary, so you can be helped out of the chair. The Plan denied your request. The Plan says the coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. We asked our 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 reclining chair repair. Our reviewer says that Medicare coverage criteria are not met for the repairs for the reclining power wheelchair. The reviewer found you do not meet the coverage criteria for the lift mechanism, therefore you do not meet criteria for repairs for a wheelchair with lift mechanism. The record does not show you're able to ambulate or that the seat lift mechanism is part of the treating practitioner's course of treatment and prescribed to improve, or stop deterioration of, your condition. We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of reclining chair repair have not been met. Therefore, we decided that the Plan does not have to pre-approve repairs to your reclining chair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pay forECG services (CPT 93000 and CPT 99214) provided to the enrollee on July 21, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysMedicare says non-urgent services should be from network providers who are contracted with the member's health planand listed in the Provider Directory.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 Plandoes not haveto pay forECG services (CPT 93000 and CPT 99214) provided to the enrollee on July 21, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan does not have to pre-approveSynvisc-One (J7325).You asked the Plan to pre-approveSynvisc-One (J7325). You say that Synvisc is medically necessary.The Plan denied your request. The Plan says the requested drug is  not on the preferred brand list of hyaluronic drugscovered by the Plan. Maximus overturned the Plans denial stating the correct contract information had not been submitted. The Plan requested a reopen and indicated the information was submitted as requested and submitted the required Plan contract a second timewith the reopen request.The Plan is correct in this case. Medicare covers allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.The Plan contract further states there are specific hyaluronic acids that are covered as preferred brands and that off brands are only covered when demonstrated to be medically necessary. Synvisc is not a on the Plans preferred brand list. There were no medical records submitted by your physician to showthe hyaluronic drugs offered by the Plan were not appropriate for your use. Therefore, we decided that the Plan does not have to pre-approveSynvisc-One (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forfoot orthotics providedon February 18, 2020.You asked the Plan to pay forfoot orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pay forfoot orthotics provided on February 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical services (33233) provided from April 8, 2020, to April 9, 2020.You asked the Plan to pay forthe surgical services. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim did not include a required device code.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 33233 is not supported in the medical record. Specifically, CPT code 33233 is a device dependent procedure that was reported without a device HCPCS code. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met.Therefore, we decided that the Plan does not have to pay forsurgical services (33233) provided from April 8, 2020, to April 9, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe radiology oncology services provided on October 6, 2020.You asked the Plan to pay forthe radiology oncology services. You say that this claim should be paid.The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary during an inpatient stay. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for this service would have been included under the global facility claim. Payment to you for this service is the responsibility of the facility or hospital.Therefore, we decided that the Plan does not have to pay forthe radiology oncology services provided on October 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor the ambulance transportation service (A0427) provided on August 6, 2020.You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.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 $225 copayment for each one-way Medicare-covered ground ambulance trip. You have been askedto pay a $225 copayment for the one-way Medicare-covered ground ambulance trip provided. 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 copaymentfor the ambulance transportation service (A0427) provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the audiology services provided on October 5, 2020, by an
out-of-network provider.
You asked the Plan to pay for the audiology services provided. You say that the Plan should pay this claim.
The Plan denied your request. The Plan says you did not request 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 had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided
that the Plan does not have to pay for the audiology services provided on October 5, 2020, by an out-ofnetwork
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on August 6, 2020 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and paid. You say that you were unaware that prior authorization was required.The Plan denied your request. The Plan says prior authorization 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.Therefore, we decided that the Plan does not have to pay forphysician services provided on August 6, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pontic and two retainer crowns provided on September 1, 2020.You asked the Plan to pay forthe pontic and retainer crowns. You say that your dental coverage does cover crowns. You also say that this service was needed to correct the extraction.The Plan denied your request. The Plan says these services are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested itemsor services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe pontic and two retainer crowns provided on September 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on November 17, 2019.You asked the Plan to pay forthe ambulance services. You say that you did not request this service.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 17, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on November 17, 2019
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 1, 2019, by an out-of-network provider.You asked the Plan to pay forthe medical services. You say that you did not receive proper notice of this member's benefit determination causing the untimely submission of the claim.The Plan denied your request. The Plansays this is past the allowed 12 month timeframeThe Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The original claim has a processed date of June 28, 2019, and this corrected claim was received on September 14, 2020. This is past the allowed 12-month timeframe. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe medical services provided on May 1, 2019, by an out-of-network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran office visit provided September 14, 2020.You asked the Plan to waive the copayment forthe office visit. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct cost-share was 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 $50 copayment for specialist visits. You have been asked to pay a $50 copayment for the office visit. The office visit falls within the specialist visits 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 office visit provided September 14, 2020