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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150).

You asked the Plan to pay for the comprehensive oral evaluation. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.

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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150), and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the neck spine (72141) and the MRI of the lumbar spine (72148) provided on October 5, 2020. You asked the Plan to waive the copayment for the MRIs. You say that you do not understand why you are being charged two separate copayments for one appointment. The Plan denied your request. The Plan says you received two MRI services. Therefore, the cost-sharing 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 $160 copayment for each outpatient radiological diagnostic service. You have been asked to pay a $160 copayment for each of the two MRIs. One MRI took an image of your neck (cervical) spine area, and the other took an image of your lumbar (lower) spine. An MRI falls within the outpatient radiological diagnostic service 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 magnetic resonance imaging (MRI) of the neck spine (72141) and the MRI of the lumbar spine (72148) provided on October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided on September 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for durable medical equipment. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating 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 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 durable medical equipment provided on September 10, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient level of care for shoulder arthroplasty surgeryYou asked the Plan to pre-approveacute inpatient hospital care. You say that you are appealing this denial.The Plan denied your request. The Plan says the denial of authorization for inpatient level of care is correct, because there is no documentation to support that the enrollee will require a greater than 2 midnight hospital stay, and this procedure can be performed as an ambulatory surgery.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at leasttwo midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewerfound the record does not show that the enrollee's necessary hospital care would be reasonably expected to span at least 2 midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient level of care for shoulder arthroplasty surgery
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve positron emission tomography (PET) scan services.

You asked the Plan to pre-approve the PET scan. You say that the records provided support the need for the requested PET scan services. The Plan denied your request. The Plan says that the records do not show why routine picture studies have failed to answer the treating physician's questions.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that the requested PET scan is medically necessary. Our physician reviewer found the enrollee has ovarian cancer and is on Tamoxifen. Our physician reviewer found that there is no requirement that says the enrollee's treatment must be chemotherapy in order to qualify for the requested PET scan. Our physician reviewer found that the requested PET scan is appropriate for use as a subsequent treatment strategy for the enrollee's condition.

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 PET scan have been met. Therefore, we decided that the Plan has to pre-approve positron emission tomography (PET) scan services.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 24, 2020. You asked the Plan to pay for the physician's services. The Plan denied your request. 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 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 physician's services. 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 physician's services provided on April 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided to you on November 3, 2020.You asked the Plan to pay forthe services. You say that you should not have to pay since you were not transported.The Plan denied your request. The Plan says without a transport there is no payable service.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 3, 2020. 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 to you on November 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve CGM. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the records do not show that you need at least 3 daily insulin injections.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear.

You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says the benefit limit has been reached.

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 Plan covers these services up to a $100 maximum benefit every 24 months.

We looked at the file and the Plan's rules. The records show that the Plan paid $100 toward the eyewear. The requested eyewear exceeds the benefit limit. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on November 17, 2020.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are only payable once per year.
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, exams and cleanings are limited to once per year. The record shows that you received an exam and cleaning on March 20, 2020, and your exams and cleanings benefits had been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on November 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0669).

You asked the Plan to pre-approve a pneumatic compression device. You say that the device is medically necessary. The Plan denied your request. The Plan says coverage criteria has been met.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show lymphedema extending onto the chest, trunk and/or abdomen. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0669).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient visit (99214) and urinalysis testing (81002, 99000) provided by an out of network (OON) provider.

You asked the Plan to pay for the outpatient visit and lab services. The Plan denied your request. The Plan says they only cover out of network services in limited circumstances. The services provided were not urgent or pre-approved.

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 outpatient visit (99214) and urinalysis testing (81002, 99000) provided 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 problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), bitewing x-ray (D0270), crown (D2740), re-cement or re-bond crown (D2920), and core buildup, including any pins when required (D2950) provided on October 6, 2020, and October 22, 2020 by an OON provider.
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, bitewing x-ray, crown, re-cement or re-bond crown, and core buildup. You say that you were told that the dental work would be covered. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that the claim was paid correctly up to the annual maximum allowable for an OON provider.
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, you are responsible for the difference between the billed amount and allowed amount. The record shows that you were advised how OON benefits were paid on a customer service call prior to the appointments. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), bitewing x-ray (D0270), crown (D2740), re-cement or re-bond crown (D2920), and core buildup, including any pins when required (D2950) provided on October 6, 2020, and October 22, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visits.

You asked the Plan to waive the copayment for the telehealth visits. You say that the copayment should be waived due to the COVID-19 pandemic. The Plan denied your request. The Plan says a waiver for telehealth services was not issued by the Plan in 2020.

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, including doctor's office visits. 

You have been asked to pay a $50 copayment for each of two telehealth visits. The telehealth visits with a specialist fall within the Physician/Practitioner services, including doctor's office 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 for the telehealth visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient therapeutic services (92507, 97110, 97116).

You asked the Plan to waive the copayments for the outpatient therapies. You say that you expected these services to be covered under the Home Health Agency benefit and would have a $0 copayment. The Plan denied your request. The Plan says that outpatient therapies are not covered by the Home Health benefit. The Plan reviewed your phone conversations with customer service and found that you were told there would still be a $40 copayment for therapy provided in the home. Additionally, the services were not provided by a Home Health Agency.

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 outpatient rehabilitation services.

You have been asked to pay a $240 copayment for the outpatient therapies. You received two days of speech therapy from one provider and four days of physical therapy from another provider. Each of these sessions requires a $40 copayment ($40 x 6 sessions = $240). 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 copayments for the outpatient therapeutic services (92507, 97110, 97116).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99310) provided by an out of network (OON) provider.

You asked the Plan to pay for the nursing facility care. You say that the services provided were medically necessary. The Plan denied your request. The Plan says they only cover out of network services in limited circumstances. The provided services in this case were not urgent or pre-approved. This care could have been provided in-network.

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 subsequent nursing facility care (99310) provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the lumbar spine (72148). You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the MRI is medically necessary. The Plan denied your request. The Plan says the records do not show that the member has pain that has not improved after 6 weeks of conservative treatment. The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that this request for MRI lumbar spine will be considered not medically necessary at this time. Our physician reviewer found based on the provided documentation, there was insufficient objective findings suggestive of a progressive radiculopathy or other red flag diagnosis or plans for a procedure which would require MRI. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the lumbar spine (72148).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Inpatient Psychiatric Hospital Services provided May 11, 2020, through May 19, 2020.
You asked the Plan to waive the copayment for Inpatient Psychiatric Hospital Services. You say that you received inadequate care from the provider and therefore should not be responsible for the copayment. 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 $298 copayment per day, days 1 to 7 for Inpatient mental health care. You have been asked to pay a total of $1,761.00 as your copayment for the Inpatient Psychiatric Hospital Services. These services fall within the Inpatient mental health care benefit category. Your total cost share is less than or equal to your copayment amount of $298 per day for days 1 to 7. 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 Psychiatric Hospital Services provided May 11, 2020, through May 19, 2020.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.