Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479) provided on September 27, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says there was no prior-authorization for these out-of-network 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 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 genetic testing (81479) provided on September 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for IV tubing (S1015) and infection control supplies (S8301) provided on October 21, 2020.
You asked the Plan to pay for the IV tubing and infection control supplies. You say that you would like reconsideration based on the records submitte4d. The Plan denied your request. The Plan says CPT codes S1015 and S8301 have status indicators of I meaning they are not valid for Medicare purposes.
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 S1015 and S8301 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT codes S1015 and S8301 have status indicators of I. This means that these CPT codes are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the IV tubing and infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for IV tubing (S1015) and infection control supplies (S8301) provided on October 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the limited oral evaluation - problem focused (D0140), panoramic radiographic image (D0330), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided September 8, 2020.
You asked the Plan to provide additional payment for the limited oral exam, panoramic x-ray and tooth extraction. You say that you disagree with the charges. The Plan denied your request. The Plan says you have met the frequency limit for the limited oral evaluation and the remaining services were correctly paid by the Plan. Since the services were provided by an out-of-network (OON) provider you are responsible for any remaining charges.
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 limited oral exam, panoramic x-ray and tooth extraction up to the Plan's frequency limits. We looked at the file and Medicare rules. The Plan provided documentation showing a limited oral evaluation has been covered within the same Plan year as the requested service. Additionally, the services were provided OON therefore, the provider is allowed to charge the difference between the maximum allowed amount and the total amount billed by the provider. Based on this information, we decided that the Plan does not have to provide additional payment for the limited oral evaluation - problem focused (D0140), panoramic radiographic image (D0330), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided September 8, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the ER visit provided on October 20, 2020.

You asked the Plan to waive the co-payment for the ER visit. You say that you were not aware of how strong the medication was and had to go to the emergency room. You say that you were given a checkup and left in a hallway. The Plan denied your request. The Plan says the co-payment applied correctly.

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 $50 co-payment for emergency care. Your co-payment will be waived if you are admitted to the hospital within 24 hours. If you are in an observation status the co-payment still applies.

You have been asked to pay a $50 co-payment for the ER visit. The 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 co-payment for the ER visit provided on October 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care from May 25, 2021, forward.
You asked the Plan to pre-approve inpatient mental health care. You say that inpatient mental health care is medically necessary. The Plan denied your request. The Plan says rules for inpatient mental health care from May 25, 2021, forward have not been met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our reviewer says that the requested inpatient mental health care is not medically necessary and reasonable. Our physician reviewer found that you are a 60-year-old male who was involuntarily admitted to the acute inpatient psychiatric hospitalization on April 20, 2021, with Schizophrenia Unspecified Type and Major Neurocognitive Disorder with Behavioral Disturbance. Based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of May 25, 2021, forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. You were able to perform activities of daily living and were awaiting placement. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care from May 25, 2021, forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MTHFR genetic testing.

You asked the Plan to pre-approve genetic testing. You say that this test is vital to the enrollee's health as this can prevent her from having a heart attack, stroke, or other clotting issues in the future if appropriately treated. The Plan denied your request. The Plan says this testing is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that MTHFR genetic testing is considered investigational and is not covered by Medicare. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve MTHFR genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluid Flow injection services.
You asked the Plan to pre-approve the requested services. You say that the enrollee has constant pain. The Plan denied your request. The Plan says there are not enough studies to show the requested service is safe and effective.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee has Rheumatoid Arthritis which effects his hands. He had stopped his medications because he was concerned that they would make him more susceptible to Covid infection. The request is for the injection of Fluid Flow into the joints of the hand. This would be an experimental/ investigational use of this medication. Therefore, the request is deemed not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve Fluid Flow injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 months of the ForeSeeHome monitoring system for the enrollee.
You asked the Plan to pre-approve the system. You say that this is mediclaly necessary. The Plan denied your request. The Plan says the documentation fails to indicate any sufficient literature to establish the effectiveness of this system.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the enrollee has age related macular degeneration. The submitted medical records do not establish the medical necessity and reasonableness of the requested service compared to standard of care therapy. 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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 months of the ForeSeeHome monitoring system for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair electronic connection.

You asked the Plan to pre-approve Power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors (E2311). You say that the enrollee needs a Group 3 power wheelchair with power tilt and power recline. The Plan denied your request. The Plan says the electronic connector is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. 

The file shows that there is not a medical need to control the power options through the joystick. The power options comes with their own switches. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair electronic connection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does was not required to provide coverage for these dental services.

You asked the Plan to pre-approve dental services. The Plan denied your request. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract criteria.

The Plan states that Maximus overturned the denial stating the Evidence of Coverage does not provide rules on restrictions for dental benefits. However, the Plan notes that on page 62 of the Plan contract, it states prior authorization rules and restrictions may apply to dental benefits. The Plan further states the Office Reference Manual outlines all covered codes and dental codes D2950 and D2740 are not listed as covered codes for this enrollee.

The Plan is correct in this case. Medicare does not cover dental benefits. The Plan covered dental services in 2019 however those benefits had restrictions and limitations. For a dental service to be covered by the Plan it had to be listed in the dental benefit contract. Based on review of the case file and the reopen request, the services requested were not covered under the Plans dental benefit at the time they were requested. Therefore, we have decided on reopen review that the Plan does not have to provide coverage for these dental services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery provided on November 23,
2020.
You asked the Plan to waive the copayment for the cataract surgery. You say that you should not owe the
provider anything and the bill should be taken care of. The Plan denied your request. The Plan says the
copayment applied correctly.
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 $25
copayment for surgery services at an in-network ambulatory surgical center.
You have been asked to pay a $25 copayment for the cataract surgery. The cataract surgery falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" 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 cataract surgery provided
on November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on October 22, 2020.

You asked the Plan to waive the copayment for specialist services. You say that you would like this paid by the Plan.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 $50 copayment for physician/practitioner services/specialist. 

You have been asked to pay a $50 copayment for specialist services. The correct copayment has been applied to the services that were provided. Specialist services falls within the physician/practitioner services/specialist 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 specialist services provided by a participating provider on October 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve primary closure of a sinus perforation (D7261).

You asked the Plan to pre-approve primary closure of a sinus perforation. You say that the dental surgery is necessary, and you cannot afford it. The Plan denied your request. The Plan says this service is not covered under your dental benefits.

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 primary closure of a sinus perforation (D7261).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program (92004) provided March 4, 2021.
You asked the Plan to waive the copayment for the medical eye exam. You say that the consult was a waste of time since the provider can only do the cataract surgery at a non-participating facility and you do not want to pay for it. The Plan denied your request. The Plan says the copayment was applied correctly.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 $40 copayment for routine eye exams or Medicare-covered non-routine eye exams. We looked at the file and the Plan's rules. You have been asked to pay a $40 copayment for the eye exam. 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. Based on this information, we decided that the Plan's rules for coverage of the medical eye exam have not been met. Therefore, we decided that the Plan does not have to waive the copayment for the ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program (92004) provided March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transtelephonic rhythm strip pacemaker evaluation
(93293) provided on March 2, 2020, by an OON provider.

You asked the Plan to pay for the transtelephonic rhythm strip pacemaker evaluation. You say that you would
like reconsideration because authorization is not needed for network providers. The Plan denied your request.
The Plan says this service was not urgent, emergent or approved in advance

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 the transtelephonic rhythm strip pacemaker
evaluation (93293) provided on March 2, 2020, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for 3D echocardiogram (76376) transthoracic echocardiography (93306) provided December 17, 2020.
You asked the Plan to waive the copayment for the diagnostic services. You say that you did not realize that the testing done was not a part of the specialist visit and was told by the receptionist that the testing was a part of the visit. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.
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 $15 copay per visit for laboratory tests, non-radiological diagnostic tests, flat film x-rays and ultrasounds. You have been asked to pay $15 copay for the diagnostic services. The diagnostic services fall 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 3D echocardiogram (76376) transthoracic echocardiography (93306) provided December 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain fused to metal crown (D2750) for tooth # 2.
You asked the Plan to pre-approve the dental service. You say that your 2020 plan covered 2 crowns per year. You say that you were not able to get any crown in 2020 due to Covid-19. You say that you would like to use your unused benefit from last year to cover the crown for tooth # 2. You also say that you cannot wait until 2022 to have this crown done. The Plan denied your request. The Plan says routine dental services are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a porcelain fused to metal crown (D2750) for tooth # 2.
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 you would like reconsideration because the IRF admission is medically necessary. The Plan denied your request. The Plan says the member's medical and rehabilitation needs are not complex may be met in a lower 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 complexity of the member's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no complex nursing or rehabilitation needs. 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.