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

We decided that the Plan does not have to pay for the office visit provided on November 20, 2019.
You asked the Plan to pay for the physician service. You say that the enrollee was not enrolled in hospice at the
time the service was rendered. The Plan denied your request. The Plan says The Medicare hospice benefit,
through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of
discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also covers
attending physician services and all care unrelated to the terminal illness until the first day of the month
following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on November 19, 2019. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the office visit
provided on November 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituximab.
You asked the Plan to pre-approve Rituximab. You say that the requested Rituximab is medically necessary. The Plan denied your request. The Plan says the requested Rituximab is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Rituximab. Our reviewer says that the requested Rituximab is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is noted to have nephrotic syndrome due to membranous glomerulonephritis. While rituximab has an off-label indication for use in lupus nephritis, it has no indication for use in nephrotic syndrome or membranous glomerulonephritis. The Mentor study mentioned by the provider was a non-inferiority study that showed that rituximab was non-inferior to cyclosporine in the treatment of membranous nephropathy. While the results are promising and should invoke further study, the use of rituximab for such conditions is still considered experimental. The requested drug is not shown to be medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituximab have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituximab.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse the full amount for the urgent care services you received
on December 30, 2019.
You asked the Plan to reimburse the full amount. You say that you should be reimbursed the full amount. The
Plan denied your request. The Plan says you are responsible for the copayment.
Review of the file shows that you received urgent care services on December 30, 2019. The services were
allowed at the Medicare amount of $85.33. You paid the full billed amount of $143 at the time of the visit. The
plan reimbursed you $45.33, which is the Medicare amount minus the required $40 copayment. 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. The amount you paid to the noncontract
provider in excess of the Medicare allowed amount must be recouped from the non-contract provider.
Maximus does not have jurisdiction over this excess amount. Therefore, we decided that the Plan does not have
to reimburse the full amount for the urgent care services you received on December 30, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Procrit.
You asked the Plan to pre-approve Procrit. You say that the requested Procrit is medically necessary. The Plan denied your request. The Plan says that the requested Procrit is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Procrit. Our reviewer says that the requested Procrit is medically necessary. Our physician reviewer found this review relates to a request for Procrit to treat an enrollee with anemia due to stage 3 chronic kidney disease, not on dialysis. The documentation indicates that the enrollee has been on the drug since 10/18/19. Before initiating the drug, the note of 3/16/20 states her hemoglobin was 8.8, iron level was 136, TIBC was 308 iron saturation was 4 and ferritin was 278 on 10/15/19. However, iron saturation is calculated as the iron level divided by the TIBC which equals 136/308=0.44 or 44%. Therefore, the saturation stated in the note is incorrect. She has been prescribed iron supplementation with Feosol twice daily. On 3/16/20 her estimated creatinine clearance was 39 and her hemoglobin is 9.7. The red cell indices are normal. Clinical Pharmacology states supplemental iron is indicated if serum ferritin is less than 100 mcg/L or when transferrin saturation is less than 20%. The enrollee had a ferritin of over 100. Therefore her iron status was adequate. The use of Procrit is FDA approved for treatment of anemia due to chronic kidney disease (CKD) in patients on dialysis and not on dialysis. The documentation supports that Procrit is medically reasonable and necessary 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 Procrit have been met. Therefore, we decided that the Plan has to pre-approve Procrit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Reblozyl.
You asked the Plan to pre-approve Reblozyl. You say that the requested medication is necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 Reblozyl. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found the enrollee is noted to have
myelodysplastic syndrome (MDS) without ring sideroblasts. Luspatercept is indicated for the treatment of
enrollees with MDS with ring sideroblasts. Therefore, the requested drug is not indicated for the enrollee's
MDS.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have
to pre-approve Reblozyl.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions.
You asked the Plan to pre-approve dental extractions. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested services exceed your benefit limit.
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 services exceed those
among those covered under this benefit. You are requesting15 dental extractions. The plan covers two (2)
extractions per calendar year. Therefore, we decided that the Plan does not have to pre-approve dental
extractions.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endoscopic decompression of the spinal cord (62380).
You asked the Plan to pre-approve endoscopic decompression of the spinal cord. You say that the services are
medically necessary. The Plan denied your request. The Plan says medical necessity has not been established.
Therefore, coverage criteria has not been 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 endoscopic decompression of the spinal
cord. Our reviewer says that the requested services are not considered medically reasonable and necessary in
this case. Our physician reviewer found endoscopic spinal cord decompression remains experimental for
treatment of spinal canal lesions and stenosis. More research is needed to show safety and efficacy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of endoscopic decompression of the spinal cord have not been met. Therefore, we
decided that the Plan does not have to pre-approve endoscopic decompression of the spinal cord (62380).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that the requested provider specializes in cyberknife therapy. The Plan denied your request. The Plan says your treatment can be safely rendered 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve oncology 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 the periodontal maintenance (D4910) provided on January 10, 2020.
You asked the Plan to reimburse you for the dental service. You say that you have periodontal disease. You say that your routine cleanings are considered periodontal prophylaxis. You also say that the periodontal maintenance should be paid just as the routine prophylaxis would be. The Plan denied your request. The Plan says periodontal maintenance is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, periodontal maintenance is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on January 10, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to hold you harmless for outpatient physical therapy services provided from
January 2, 2020 to January 15, 2020.
You asked the Plan to hold you harmless for physical therapy. You say that you would have had no problem
securing authorization, but the provider told you that they did not need any authorization. The Plan denied your
request. The Plan says that the denial of payment for these services is correct, because authorization was not
obtained and these services did not meet Medicare criteria for coverage.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
These services were performed by an in-network provider. The file does not show that the Plan provided notice
that physical therapy would not be covered. Under Medicare rules, this means physical therapy is considered
approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the denial of outpatient
physical therapy services provided from January 2, 2020 to January 15, 2020.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on June 17, 2019.
You asked the Plan to pay for drug test. You say that you are appealing with documentation. The Plan denied
your request. The Plan says the denial of payment for this service is correct, because the documentation
submitted does not include a valid physician order, lab requisition, or medical records stating exactly which
tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a physician order or
clear intent to order the specific lab service billed on this claim. Based on this information, we decided that
Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have
to pay for drug testing provided on June 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Acetaminophen 325mg tablets.You asked the Plan to pre-approve Acetaminophen. You say that the drug is medically necessary.The Plan denied your request. The Plan says coverage for this drug is not available under the Part B medical benefit.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 Acetaminophen 325mg tablets.Benefits for Acetaminophenmay 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on November 15, 2019.
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that CTC testing is non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on November 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the golf services you received on January 13, 2020.You asked the Plan to reimburse fo rthe golf services. The Plan denied your request. The Plan says the receipt does not show your name.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers fitness benefits only when an itemized receipt or other proof of payment and proof of participation are submitted..The Plan's rules for coverage of gym benefits have not been met because the submitted receipt does not show participation by the enrollee. While the receipt does show proof of payment by the enrollee, the receipt does not indicate that the enrollee was the participant in the golfing activity, as a different name is shown on the receipt.Therefore, we decided that the Plan does not have to reimburse for the golf services you received on January 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 20611 provided on August 12, 2019.
You asked the Plan to pay for CPT code 20611. You say that the medical records support the billing of CPT code 20611. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 20611.
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 is Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting. 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 pay for CPT code 20611. Our reviewer says that the medical records do not support the billing of CPT code 20611. Our physician reviewer found based on the documentation provided, the enrollee received an injection to the tendons of her thumb. There is no evidence that the enrollee received an injection/aspiration of a major joint. Therefore, the billing of CPT 20611 is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 20611 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 20611 provided on August 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on August 28, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the
documentation submitted did not include a physician order/lab requisition or medical records stating exactly
what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan
does not have to pay for the drug testing services provided on August 28, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided from December 4,
2019 to December 6, 2019 billed with two units of code 97110, three units of code 97112, and three units of
code 97530.
You asked the Plan to pay for the physical therapy services as billed. You say that these services should be
paid. The Plan denied your request. The Plan says documentation submitted does not indicate the amount of
time that was spent providing these services.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units
provided for each procedure code.
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 pay for the physical therapy services as billed Our
reviewer says that the number of units billed for these codes is not supported by the medical records. Our
physician reviewer found the medical records provided do not include documentation of the start and stop
times to validate the number of units of these codes. Each Healthcare Common Procedure Coding System
(HCPCS) code/Current Procedural Terminology (CPT) code has a defined unit of service for reporting
purposes. A physician should not report units of service for a HCPCS/CPT code using a criterion that differs
from code's defined unit of service for a HCPCS/CPT code using a criterion that differs from the code's defined
unit of service which is, in this case, defined by time in 15 minute intervals.
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 physical therapy services as billed have not been met. Therefore, we decided
that the Plan does not have to pay for the physical therapy services provided from December 4, 2019 to
December 6, 2019 billed with two units of code 97110, three units of code 97112, and three units of code
97530.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on November
19, 2019.
You asked the Plan to waive the copayment for urgent care visit. You say that this provider did not do anything
for you but referred you to the hospital. The Plan denied your request. The Plan says the copayment amount
you are 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). Your contract with the Plan clearly says that you must pay $20
copayment for urgent care visit.
You have been asked to pay $20 copayment for urgent care visit. Urgent care visit falls within the Urgently
Needed 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 an urgent care visit
provided on November 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full cast high noble metal crown (D2790) provided on January 13, 2020.
You asked the Plan to pay for the dental service. You say that you received a treatment plan from your provider that stated the plan would pay approximately $368 for the crown. You say that this non-payment was totally unexpected. You also say that it left you with sudden financial difficulty. The Plan denied your request. The Plan says the crown is not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full cast high noble metal crown (D2790) provided on January 13, 2020.