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

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 17, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available 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 services at issue in this appeal. 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 the services provided by an out-of-network provider on July 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for retainer crowns (D6740) and a porcelain/ceramic pontic (D6245) for a fixed bridge provided on January 7, 2021.

You asked the Plan to pay for the fixed bridge. You say that the crowns should be covered because the benefit lists crowns as a covered service. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental benefit.

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. Please note that retainer crowns are a specific type of crown and are not one of the procedures/items listed as covered under this benefit. Therefore, we decided that the Plan does not have to pay for retainer crowns (D6740) and a porcelain/ceramic pontic (D6245) for a fixed bridge provided on January 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can safely be received in other settings, for example: a skilled nursing
facility.

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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a
transient ischemic attack. Medical problems are stable. There are no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy,
and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary
care can be provided in a different level of care. There is not a reasonable expectation that you will be able to
fully participate in and 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. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on September 22, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 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 the services provided by an out-of-network provider on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap vaccine you received on December 28, 2020.

You asked the Plan to pay for the vaccine. You say that you got the vaccine because your provider told you to. The Plan denied your request. The Plan says this is not covered under your Part B plan.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. 

The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the Tdap vaccine you received on December 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy services (97140, 99213, 97161) provided November 26, 2019 to December 23, 2019.

You asked the Plan to waive the copayment for the PT services. You say that you did not receive reimbursement of your copays and have included receipt copies. The Plan denied your request. The Plan says the claims were processed and the correct copayments were 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 $10 copay for each Medicare covered outpatient rehabilitation service visit. 

You have been asked to pay $80 ($10 x 8 PT visits) for the PT services. The PT services falls within the Outpatient rehabilitation services 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 physical therapy services (97140, 99213, 97161) provided November 26, 2019 to December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based fillings (D2392, D2394), core buildup (D2950) and root canal (D3330) provided from October 5, 2020 to November 16, 2020.

You asked the Plan to pay for the dental services. You say that you signed up for the additional optional dental rider and were told that your dental coverage would increase. You feel that you were misled and cannot afford the amount you are being billed. The Plan denied your request. The Plan says you have met and exceeded the annual $1,000 limit for dental services. The core buildup procedure is not a covered service under this benefit. The Plan states that they have also reviewed your call log with customer service and have determined that you were told that there was $1,000 of coverage with this benefit, not $1,500.

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 or were provided in excess of the $1,000 annual limit. Therefore, we decided that the Plan does not have to pay for resin-based fillings (D2392, D2394), core buildup (D2950) and root canal (D3330) provided from October 5, 2020 to November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the ophthalmological services:
medical examination and evaluation, with initiation or continuation of diagnostic and treatment program
(92014) provided November 24, 2020.

You asked the Plan to pay for the eye exam. You say that you have received two different charges for the
services by the provider and the facility and should not be responsible for the copayment. The Plan denied your
request. The Plan says that the copayment for the eye exam has been 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. Your contract with the Plan clearly says that you must pay a $40 copayment for each Medicare covered
eye exam to treat an eye condition.

You have been asked to pay a $40 copayment for the eye exam. Eye exams fall within the vision 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, it is
our decision that the Plan does not have to provide any additional payment for the ophthalmological services:
medical examination and evaluation, with initiation or continuation of diagnostic and treatment program
(92014) provided November 24, 2020.

Your complaint about how the provider and facility have billed your services is not a valid appeal for medical
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not
permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 2, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 services at issue in this appeal. 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 the services provided by an out-of-network provider on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 15, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that office visits do not require an authorization. The Plan denied your request. The Plan says prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The file shows that the enrollee was seen for a follow-up visit. The 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 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 the office visit provided on October 15, 2020 by an out of network (OON) provider.
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 disagree with the denial. The Plan denied your
request. The Plan says the services are not medically necessary.

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 medically necessary. Our physician reviewer found the enrollee was admitted to the
hospital for pneumonia. She is now medically stable with no complex nursing or rehabilitation needs. She does
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a
reasonable expectation that the enrollee will be able to fully participate in and 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. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on August 12, 2020.

You asked the Plan to pay for the ambulance service and ground mileage. You say that the enrollee was not under hospice care when these services were provided. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance service and ground mileage provided on August 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on July 27, 2020.

You asked the Plan to pay for this testing. You say that this claim should be paid. 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 case file and the reopen request. At issue is coverage for ConfirmMDx. Maximus overturned the Plans denial for insufficient case file information. The Plan requested a reopen and provided additional information regarding their decision. Our Medical Director has concluded that the Plan is correct in this case. The enrollee is a 70-year-old man with an elevated PSA. A prostate biopsy was performed on July 28, 2020. ConfirmMDx was ordered as an ancillary test. ConfirmMDx is only covered when specific criteria are met. The documentation does not support that the enrollee is being considered for a repeat biopsy due to persistent or elevated cancer-risk factors. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on July 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for biopsy services provided on February 8, 2021.

You asked the Plan to waive the copay for the services provided. You say that you had the biopsy in the same room as ultrasounds you had one. The Plan denied your request. The Plan says you are responsible for the copay.

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 $250 copay for outpatient surgery. 

The file shows that you received a breast biopsy, which is a surgical procedure. You have been asked to pay a $250 copay for the services provided. The services fall within the outpatient surgery 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 copay for biopsy services provided on February 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says prior authorization criteria were not met.

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 monitor. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the enrollee is not treated with insulin. The elements of the coverage rule are not satisfied. 

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered December 9, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 37246 is not supported.

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 37246 is transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery; initial artery. 

We find that CPT code 37246 is not supported in the medical record. Specifically, there is no documentation of a transluminal balloon angioplasty with open or percutaneous approach. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered December 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a low-dose computed tomography (LDCT) lung cancer screening provided on September 8, 2020.

You asked the Plan to pay for LDCT lung cancer screening. You say that you are appealing with supporting records and this was provided with a payable diagnosis. The Plan denied your request. The Plan says the denial of payment for this test is correct, because the enrollee did not meet the Medicare eligibility criteria due to age and concerns of signs of lung cancer on previous imaging.

The Plan must follow Medicare rules. Medicare rules say that LDCT lung cancer screening is only covered for enrollees who meet certain eligibility criteria.

We looked at the file and Medicare rules. At the time this test was performed, the enrollee was not within the covered age range of 55 to 77 years. Based on this information, we decided that Medicare rules for coverage of LDCT lung cancer screening have not been met. Therefore, we decided that the Plan does not have to pay for a low-dose computed tomography (LDCT) lung cancer screening provided on September 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on August 13, 2020.

You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage criteria are not met. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and stated that the QIC did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. Our Medical Director has concluded that the Plan is correct in this case. The enrollee was a then 68-year-old man with an elevated PSA. The enrollee underwent a biopsy on August 13, 2020. ConfirmMDx was ordered as an ancillary test. The documentation does not support that the enrollee is being considered for a repeat biopsy due to persistent or elevated cancer-risk factors. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary-level referral to a surgical oncologist.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no support for care with a highly specialized provider at this time.

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 referral. Our reviewer says that the
requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer
found the treatment of melanoma, including need for sentinel node biopsy, surveillance and even therapy can
be handled by in network provider. There is no need for a tertiary level of care.

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 referral have not been met. Therefore, we decided that the Plan does not
have to pre-approve a tertiary-level referral to a surgical oncologist.