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

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure remains experimental for the treatment of low back pain. More research 
is needed to show safety and efficacy of the procedure. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the complete denture - maxillary and complete denture - mandibular. You 
say that you would like to be pre-approved for new dentures. The Plan denied your request. The Plan says you 
have exhausted your benefit for the services requested. 
 
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 complete 
denture - maxillary and complete denture - mandibular when the services are medically necessary and 
reasonable.  
 
We looked at the file and Medicare rules. The file indicates that you last received these services in June 2020. 
Therefore, you have exhausted the benefit for complete dentures until June 2025. Based on this information, we 
decided that the Plan's rules for coverage of the complete denture - maxillary and complete denture - 
mandibular have not been met. Therefore, we decided that the Plan does not have to pre-approve the complete 
denture - maxillary (D5110) and complete denture - mandibular (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) for tooth # 6 provided on September 24, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you were advised you needed 5 frontal crowns. 
You say that your provider advised that 2 crowns were covered. You say that you received an excessive bill for 
$1,482.30. You say that you should only be held responsible for 1 crown as that is what you were told initially. 
The Plan denied your request. The Plan says that 1 crown per covered per calendar year with a 70% 
coinsurance. The Plan says that you were reimbursed for the crown for tooth # 7 that you received on this date 
of service. The Plan also says that the frequency limit for crowns 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, the frequency limit for crowns has 
been exceeded. Therefore, we decided that the Plan does not have to pay for the crown (D2740) for tooth # 6 
provided on September 24, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan does not have to pay additional reimbursement for these dental services. You asked the Plan to reimburse the full amount of these services. You say that you believe the Plan should cover more of the cost of the services provided.The Plan denied your request. The Plan says this cost share was applied based on the services provided and your Plan contract agreement for dental services. Maximus overturned the Plans denial. The Plan requested a reopenand provided additional information regarding your dental claims. The Plan says that you are appealing the copayment that applied to dental services which included cleaning, bitewing x-rays, periodic oral evaluation, and 5 fillings provided from January23, 2020, to March 10, 2020. The Plan did not deny these services. The enrollee is responsible to pay 50% coinsurance for comprehensive dental services. Per the 2020 Evidence of Coverage the enrollee is responsible for 50% coinsurance for comprehensive dental services. The enrollee's benefit is not 100% reimbursement for all dentalservices. The enrollee's benefit is $0 copayment for preventive dental services (Dub, D0274 and D0120) and 50% coinsurance for comprehensive dental services (D2392, D2332, D2391and D2330). The Plan paid the enrollee for its share and the enrollee is responsible for the coinsurance for D2392, D2332, D2391 and D2330.Based upon the Health Plan's review of the information provided, the Plan is upholding the enrollee's coinsurance that applied to the dental services in theThe Plan is correct in this case. 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 Plan applied the coinsurance correctly per the 2020 dental benefits. Therefore, we decided that the Plan does not have to pay additional reimbursement for dental services provided from January 23, 2020, to March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dialysis services provided from July 2,
2020, to August 29, 2020.

You asked the Plan to waive the coinsurance for the dialysis services. You say that you met your maximum
out-of-pocket amount and should not be responsible for these amounts. The Plan denied your request. The Plan
says you have been charged the correct cost sharing amount.

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 20%
coinsurance for in-network Medicare-covered benefits for outpatient dialysis treatments.

You have been asked to pay $50 which is 20% of the allowed amount for the dialysis on each date of service.
The allowed amount is $250. ($250 x 20% = $50). ($50 x 22 dates of service = $1,100). The dialysis services
fall within the "Services to Treat Kidney Disease" benefit category. The record shows you met $4,188.99 of
your $4,900 maximum out-of-pocket amount after these claims were processed.

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 the dialysis services provided from July 2, 2020, to August
29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested 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 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 the enrollee was admitted for a stroke and COVID-19. The enrollee's medical 
conditions are stable. The documentation does not support that the enrollee requires an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the 
enrollee requires an 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron 4mg odt tablet. 
 
You asked the Plan to pre-approve Ondansetron. You say that the item is medically necessary. The Plan denied 
your request. The Plan says Ondansetron ODT tablet is an oral self-administered drug 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron 4mg odt 
tablet.  
 
Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on May 20, 2020. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you thought this was covered by 
insurance. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $155 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a 
physician's office or at a freestanding facility (such as a radiological center or medical clinic). For this date of 
service, you have been asked to pay the allowed amount of the claim because this amount is less than the $155 
copayment for the ultrasound. 
 
You have been asked to pay a $131.81 copayment for the ultrasound. The ultrasound falls within the 
"Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the ultrasound provided on May 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an L3-5 decompression and fusion for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of these services in the setting 
of multifactorial low back and bilateral lower extremity pain have not been demonstrated in the peer reviewed 
literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The medical records 
do not show that adequate conservative measures have been tried and failed. A 6-week trial of recent physical 
therapy is needed. There are no red flags for surgery at this time. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an L3-5 decompression and fusion for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cytopathology services (CPT 88104) provided to the enrollee 
on August 19, 2020. 
 
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 CPT 88104 is payable with modifier 59 per NCCI edits. 
 
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 88104 is "Cytopathology, fluids, washings or brushings, 
except cervical or vaginal; smears with interpretation." 
 
We asked our coder 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 pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found CPT 88104 
can be billed with CPT 88112 with modifier 59, if separate specimen.  The documentation submitted does not 
specify a separate specimen, therefore modifier 59 cannot be verified. 
 
We looked at this coder'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 pay for cytopathology services (CPT 88104) provided to the enrollee on August 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio (J3380). You asked the Plan to pre-approve Entyvio. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drugs. The Plan also says there is no indication that the preferred drugs would likely be less effective or cause adverse effects for the enrollee. 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 Entyvio. Our reviewer says that the requested drug, Entiyvio, is not medically necessary. Our physician reviewer found the provided documentation does not shows that the enrollee has tried and failed the required drugs. The reviewer also found that there is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio (J3380).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-network (OON) provider.You asked the Plan to pre-approve the limb prosthesis. You say that you do not want to use the network provider because a friend had a bad experience there.The Plan denied your request. The Plan says you do not have a network gap or an emergency situation that would necessitate the use of an out of network 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses providedon August 12, 2020.You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says you have already used you full $250 allowance for supplemental eyewear for the plan year 2020.Medicare generally does notcover routineeyewear services. However, the Plan offers a routineeyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.We looked at the file and the Plan's rules. The file shows that you have previously used your full $250 allowance for eyewear.Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses providedon August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5261) purchased on January 16, 2020 from an out-of-network provider.
You asked the Plan to pay for hearing aids. You say that you believed this provider was in-network. The Plan denied your request. The Plan says this provider is not in-network for supplemental hearing services.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from an in-network vendor. We looked at the file and the Plan's rules. The hearing aids at issue were not purchased from an in-network vendor. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5261) purchased on January 16, 2020 from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services received on September 14, 2020.You asked the Planto pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the provider is not enrolled in the Medicare program.The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program.The rendering provider is not eligible to bill Medicare. did not pre-approve the services. We found no exception that would require to pay for these items/services. 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 therapy services received on September 14, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 4, 2020 by a non-contracted provider.You asked the Plan to pay forthe durable medical equipment (DME). You say that you called to ask if it was approved and got different answers that it wouldn't be covered and that it would be covered.The Plan denied your request. The Plan says the items were not obtained through a Medicare Approved DME Provider.Medicare rules say that plans can require enrollees to get care from network providers. These non-emergency use DME items were purchased through Amazon.com who is not a Medicare Approved DME provider. The member self-referred to Amazon.com. As per member'sEvidence of Coverage "You can get your care from an out-of-network provider, however, in most cases that provider must be eligible to participate in Medicare." Except for emergency care, the Plan will not pay a provider who is not eligible to participate in Medicare. If you receive care from a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. 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, wedecided that the Plan does not have to pay forthe medical services provided on July 4, 2020 by a non-contracted provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on November 8, 2019.You asked the Plan to pay forthe ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.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 8, 2019. 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 on November 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the Travel CPAP, humidifier and cord purchased 
on September 18, 2020. 
 
You asked the Plan to reimburse you for the Travel CPAP humidifier and cord. You say that you were told the 
CPAP would be covered. The Plan denied your request. The Plan says an additional CPAP for traveling 
purposes is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. The rules state that for equipment to be covered, it must be appropriate and needed 
for use inside the home. 
 
The file shows that you had a CPAP at the time the Travel CPAP, humidifier and cord was received. Your 
CPAP serves the same purpose as the Travel CPAP and supplies. The CPAP at issue in this appeal is for use 
outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for 
use outside the home.  Therefore, we decided that the Plan does not have to reimburse you for the Travel 
CPAP, humidifier and cord purchased on September 18, 2020.