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

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).

You asked the Plan to pre-approve the dental item. You say that your current denture is too loose. You say that
you have to hold them in with your tongue. You say that you cannot eat with them in your mouth. You also say
that you have lost 50 pounds in the last year because you cannot eat properly. The Plan denied your request.
The Plan says 1 upper denture is covered every 60 months. The Plan also says that the frequency limit for this
service has been reached.

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 frequency limit for this service has
been reached. The record shows that the Plan paid for an immediate upper denture (D5130). Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient mental health services.

You asked the Plan to pay for inpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says that the claim has been denied.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan failed to provide the IRE with a copy of the denial rationale or any documentation to support the denial. The plan failed to provide the IRE with a copy of the appeal request. Documentation submitted to the IRE was limited to medical records and a copy of the Waiver of Liability form. Additional documentation was requested from the plan and was not received. Therefore, we decided that the Plan has to pay for inpatient mental health 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the external infusion pump rental.

You asked the Plan to pay for the external infusion pump rental. You say that these claims should be paid due to medical necessity. The Plan denied your request. The Plan says these infusions were started during physician visits. As such, the payment for the equipment is included in the payment made to the provider who began the infusion.

The Plan must follow Medicare rules. Medicare rules say that when drug infusions that require prolonged administration through an external pump are initiated in a physician's office, payment for the drug and the equipment is included in the payment made to the physician or facility.

In this case, the infusion of these chemotherapy drugs was initiated in the Hospital. Payment for the related equipment cannot be made separately to the equipment supplier as it is included in the payment to the hospital. Therefore, we decided that the Plan does not have to pay for the external infusion pump rental.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045).

You asked the Plan to pay for an x-ray. You say that this service was rendered in an appropriate place of service. The Plan denied your request. The Plan says this was not billed with the correct POS code.

The Plan must follow Medicare rules. Medicare rules say that that when a physician/practitioner furnishes services to a registered inpatient, payment is made under the PFS at the facility rate. To that end, a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter.

We looked at the file and Medicare rules. The record shows that the enrollee was registered as an inpatient at the time this service was rendered, but this service was billed with POS code 22 for outpatient hospital. Based on this information, we decided that Medicare rules for coverage of an x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045).
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 a skilled nursing facility will not provide adequate physician, nursing and therapy coverage and care. The Plan denied your request. The Plan says that the enrollee can safely receive the needed care in another setting.

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. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox for the enrollee.

You asked the Plan to pre-approve Botox. You say that this is medically necessary. The Plan denied your
request. The Plan says that the enrollee does not have any stated contraindications to the preferred products.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Botox. Our reviewer says that Botox is
not medically reasonable and necessary for the enrollee. The patient has not tried and failed Dysport or
XEOMIN. There is no documentation provided indicating that Dysport or XEOMIN would likely be less
effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's
condition does not meet step therapy criteria for Botox.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to
pre-approve Botox for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit.

You asked the Plan to waive the copayment for emergency room visit. You say that the enrollee did not recall this visit. The Plan denied your request. The Plan says the copayment amount the enrollee is being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay $100 copayment for emergency room visit.

The enrollee has been asked to pay $90, which is less than the $100 copayment for emergency room visit. Emergency room visit falls within the Emergency Room benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis coded L0650.

You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code L0650 is lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf.

We find that CPT code L0650 is not supported in the medical record. Specifically, the documentation does not support that the enrollee had ever seen the referring provider. The documentation does not support that there was an established relationship between the referring provider and the enrollee. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis coded L0650.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan does not have to pay for the bitewing x-rays provided on June 3, 2020.
You asked the Plan to pay for the bitewing x-rays provided on June 3, 2020. You say that these dental services should be covered by the Plan. The Plan denied your request. The Plan says this benefit was exhausted at the time of service. Maximus overturned the Plans denial. The Plan requested a reopen and stated that the dental plan allows benefits for bitewing x-rays once in a twelve-month period. The provider had previously covered bitewing x-rays on June 10, 2019. The records show you were not eligible for this benefit on June 3, 2020. The benefit was not available until after June 10, 2020.
The Plan is correct in this case. Medicare 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, this benefit was not available until after June 10, 2020 due to the once per year requirement. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays provided on June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D2740 and D9120).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of decay or a missing crown to support the need for replacement.
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 services when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the requests has been made for a replacement crown on tooth #21, and for sectioning of a bridge. The bridge from #18 to #20 was seen on the provided x-ray to be failing due to the decay on #18, which was treatment planned for removal. Sectioning of the existing bridge would allow for retaining the crown on tooth #20 despite the failed #18 terminal abutment, and would be reasonable, however it is not listed in the code list in plan documents and is not a covered service as coverage must be "authorized in accordance with the Plan Certificate". The existing crown on #21 does not appear to have any defective margins and has no other noted defects. In this case there is no recurrent decay seen, and the crown is not missing. Given the presentation of the case, there would be no medical necessity for replacement of the crown on tooth #21. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve dental services (D2740 and D9120).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan does not have to provide coverage for Ilumya for the enrollee.

You asked the Plan to provide coverage for this drug. You say that this drug is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the reopen request and the case file. Our Medical Director says that at issue is coverage for Ilumya (Tildrakizumab-asmn). The Maximus Physician Reviewer determined that Ilumya was medically reasonable and necessary, and that coverage was warranted based on the community standard of care. The Plan requested a reopen and stated the provider didn't indicate a reason why Remicade/Inflectra or Stelara would be inappropriate/ineffective for this member and there is no evidence in the compendia, medical literature and relevant guidelines to suggest that Ilumya is preferable to the Plan's preferred step therapy alternatives. Our Medical Director states the medical records show the enrollee is a 59-year-old man with a diagnosis of psoriasis vulgaris. Our Medical Director says the plan is correct in this case. The documentation did not support that Inflectra OR Remicade AND Stelara would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this drug have not been met. Therefore, we decided that the Plan does not have to provide coverage for Ilumya for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses, anti-reflective coating and deluxe frames.

You asked the Plan to pay for the eyeglass upgrades. You say that the eyeglasses were purchased in network. The Plan denied your request. The Plan says the provider is out of network for your supplemental vision benefit.

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 when provided by an in network provider.

We looked at the file and the Plan's rules. Medicare does not cover eyeglass upgrades and the provider is not in network with your supplemental vision benefit. Based on this information, we decided that the Plan's rules for coverage of the eyeglass upgrades have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses, anti-reflective coating and deluxe frames.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have required skilled rehab services to improve function due to weakness and deconditioning. There are no skilled nursing needs. The most recent therapy documentation indicates you no longer requires any skilled nursing or rehab services on a daily basis. You are not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or ADLs. You no longer require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you no longer require any skilled services on an inpatient basis, at a SNF level of care. You do not have any parental medications, complex wound care or nutrition given via a feeding tube. You received skilled care and improved, however your function has plateaued and you do not require any further inpatient skilled rehab services. Your function is at or near your prior level of function and you can be discharged to a lower level of care for further services. The denial for further inpatient skilled care is upheld.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that these services are provided in good faith. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that member's primary care physician did not refer these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 physician services provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Yervoy (J9228).

You asked the Plan to pre-approve Yervoy. You say that this drug is medically necessary to treat the enrollee's condition. The Plan denied your request. The Plan says Yervoy does not meet medical necessity criteria.

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 Yervoy. Our reviewer says that this service is not medically reasonable and necessary. Our physician reviewer found a chemotherapy routine with Yervoy is not appropriate for this enrollee because the enrollee has already failed PD-1 inhibitor.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Yervoy have not been met. Therefore, we decided that the Plan does not have to pre-approve Yervoy (J9228).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services are not payable as the claim was
submitted untimely.

The 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 record shows that a claim for these services was not filed until September 26, 2020. 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 for the medical services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999).

You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not separately payable.

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 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other intraoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the services 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 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.