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

We decided that the Plan does not have to pay the in network rate for the periapical x-ray (D0220), the additional periapical x-ray (D0230) and the unspecified preventive service (D1999).

You asked the Plan to pay the in network rate for the periapical x-rays and unspecified preventive service. You say that you called the plan before your appointment. You say that a plan representative advised that the provider's office was in network. You also say that if the provider was out of network, you would have found a different one. The Plan denied your request. The Plan says periapical x-rays are not listed as covered services. The Plan also says that the unspecified preventive service 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the periapical x-ray (D0220), the additional periapical x-ray (D0230) and the unspecified preventive service (D1999).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular monitoring services.

You asked the Plan to pay for the cardiovascular monitoring services. The Plan denied your request. The Plan
says 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 Plan says that the Plan has also determined that these services are
not urgent or emergent, nor were they 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 did not pre-approve the
services 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 cardiovascular monitoring services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services (HCPCS S9328) provided to the enrollee.

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 this code is not recognized.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 home infusion therapy services (HCPCS S9328) provided to the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammography (77067).

You asked the Plan to pay for the screening mammography. You say that you would like reconsideration
because the member had multiple exams on the same date of service. The Plan denied your request. The Plan
says the submitted documentation supports 1 (one) unit of 77067-26, which was previously approved/paid.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 77067 is not supported in the record. Specifically, the record shows that one unit of
CPT code 77067 was previously approved and paid by the Plan. The documentation submitted does not
indicate that this service was rendered more than once on the billed date of service. Based on this information,
we decided that Medicare rules for coverage of the screening mammography have not been met. Therefore, we
decided that the Plan does not have to pay for the screening mammography (77067).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the comprehensive oral exam (D0150), the
complete series x-ray (D0210), and the surgical extractions (D7210) of teeth #3 and 5.

You asked the Plan to reimburse you for the dental services. You say that you tried to see other dentists. You
say that you kept getting referred to an oral surgeon. You say that most oral surgeons that you were referred to
did not work with your plan. You say that you were in so much pain. The Plan denied your request. The Plan
says the provider in this case is out of network. The Plan says that you must visit a participating dental network
provider to receive dental benefits. The Plan also says that you the frequency limit of one comprehensive oral
evaluation every three calendar years has been exceeded.

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, dental services that you receive out of
network are not covered. Therefore, we decided that the Plan does not have to reimburse you for the
comprehensive oral exam (D0150), the complete series x-ray (D0210), and the surgical extractions (D7210) of
teeth #3 and 5.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services.

You asked the Plan to waive the copayment for these services. You say that you never had to pay a copayment before. The Plan denied your request. The Plan says the copayment was 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 $50 copayment per day for days 1-3 for Medicare-covered inpatient hospital care.

Review of the file shows that you received three days of inpatient care. You were not assessed a copayment. You have been asked to pay a $50 copayment per day for days 1-3 for these services, for a total of $150. These services fall within the Medicare-covered inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no trial and failure of a basic pump.

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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation does not support that the patient has objective physical exam findings of lymphedema
of the chest, trunk, or abdomen. There is no evidence of unique characteristics that would indicate the
segmented pump over a standard pump. There is no documentation of a trial and failure of the standard pump.

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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve a pneumatic compression device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction of tooth #11 and panoramic x-ray provided by an OON provider.

You asked the Plan to pay for the extraction and panoramic x-ray. You say that you would like these services to be covered by the Plan. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that no benefits are available for procedures performed by OON providers.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the extraction of tooth #11 and panoramic x-ray provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with this copayment. 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 $300 copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care.

You have been asked to pay a $300 copayment per day for days 1-6. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $600. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay for x-ray services provided to the enrollee.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial for a lack of claim information. The Plan requested a reopen and provided additional claim information. The Plan says that the submitted documentation supports 1 (one) unit of 71046-26, which was previously approved and paid to the same provider group. The Plan states there is no additional documentation supporting the additional study billed.

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 and when required the appropriate modifiers. The Plan provided documentation to show this service was previously billed and paid. The claim in question does not show this was a separate and distinct service from the claim previously billed and paid. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for x-ray services provided to the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pay for nursing services provided to the enrollee.

You asked the Plan to pay for practitioner services provided to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that this claim denied because the provider was not eligible for payment of this service. The Plan states that the NPI Registry website shows the billing provider is registered with the taxonomy code for a Nurse Practitioner.

However, the provider has billed with a Registered Nurse taxonomy. The Medicare Program Integrity Manual states that Registered Nurses are not eligible providers for this type of Medicare billing.

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 taxonomy codes. In this case, this claim cannot be paid as billed due to an issue with the reported taxonomy code. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for nursing services provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown re-cement (D2920), the periapical x-ray (D0220), the filling (D2393), the application of medicaments (D9910), the periodic oral exam (D0120), and prophylaxis (D1110).

You asked the Plan to pay for the dental services. You say that you have been seeing this dentist since 2017. You say that you were not told that they were no longer accepting your plan. You say that had you known, you would have found another dentist. You also say that $352 is a lot to budget into your winter expenses on your limited income. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that care rendered by a provider that is not part of our supplemental dental network is 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, dental services that you receive out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown re-cement (D2920), the periapical x-ray (D0220), the filling (D2393), the application of medicaments (D9910), the periodic oral exam (D0120), and prophylaxis (D1110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a preparatory prosthetic leg with an advanced foot feature (L5530, L5986, L5673, L5981, L5620, L8440, L5637, L5910, L8420, L5671, L8400).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says a request for a K2-level foot prosthesis can be reviewed if it is submitted.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the physician's documentation indicates that you appear to be chronically ill. Your medical progress reports do not corroborate that you are a K3 ambulator and require the preparatory prosthetic leg with an advanced foot feature. This request would exceed your medical need and is not 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a preparatory prosthetic leg with an advanced foot feature (L5530, L5986, L5673, L5981, L5620, L8440, L5637, L5910, L8420, L5671, L8400).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an echocardiograph (93306).

You asked the Plan to waive the coinsurance for the echocardiograph. You say that the coinsurance should be
waived. The Plan denied your request. The Plan says the correct cost-sharing 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 20%
coinsurance for diagnostic radiology.

You have been asked to pay a 20% coinsurance ($96.64) for the echocardiograph. The echocardiograph falls
within the diagnostic radiology 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 echocardiograph (93306).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve capecitabine for the enrollee.

You asked the Plan to pre-approve capecitabine. You say that this is medically necessary. The Plan denied your request. The Plan says that that the drug/regimen is not being prescribed for a supported medically accepted indication.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 capecitabine. Our reviewer says that capecitabine is medically reasonable and necessary for the enrollee. Capecitabine is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. It is supported in combination with mitomycin and radiation. Documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. Our physician reviewer found that the enrollee's condition meets criteria for capecitabine.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of capecitabine have been met. Therefore, we decided that the Plan has to pre-approve capecitabine for the enrollee.

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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room visit (99284).

You asked the Plan to waive the copayment for the Emergency Room visit. You say that the copayment should
be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 $120
copayment for Emergency Care.

You have been asked to pay a $120 copayment for the Emergency Room visit. The Emergency Room 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 for an
Emergency Room visit (99284).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient residential treatment.

You asked the Plan to pay for the inpatient residential treatment. The Plan denied your request. The Plan says
enrollees must choose in-network providers except in emergent or urgent care situations.

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 did not pre-approve the
services 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 inpatient residential treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service can be obtained at 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 above.

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 there are no complex nursing or rehabilitation needs and you do not require treatment by multiple therapies. There is not a reasonable expectation that you will be able benefit from the intensive rehabilitation therapy program provided in an IRF.

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. Specifically, records show you are able to receive services at a lower level of care. This means the IRF care is not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.