Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical services provided on
January 7, 2020.
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 a psychiatric diagnostic evaluation with medical services provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 15, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care.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 forthe medical services provided on October 15, 2020, by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible that was applied toa prostate biopsy (55700) provided on July 21, 2020.You asked the Plan to waive the deductible that was applied toa prostate biopsy. You say that you didn't know you were responsible for anything other than the copay.The Plan denied your request. The Plan says there is a $1,000 deductible for most covered services, and a prostate biopsy is one that requires a deductible.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible for most covered services. The item or service you asked the Plan to waive the deductible foris one of those services that requires a deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for most covered services. This cost sharing is a contractual obligation that had not been met at the time a prostate biopsywas received on July 21, 2020.Therefore, we decided that the Plan does not have to waive the deductible that was applied toa prostate biopsy (55700) provided on July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgery and bone grafting of the alveolar bone (21025, 21030, 41874, 21215, 21248, 21079 and 21085).
You asked the Plan to pre-approve osseous surgery and bone grafting of the alveolar bone. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not covered on your supplemental benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 osseous surgery and bone grafting of the alveolar bone. Our reviewer says that the service is not medically necessary. Our physician reviewer found items and services in connection with the care, treatment, filling, removal or replacement of the teeth or structures directly supporting the teeth are not covered. 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 osseous surgery and bone grafting of the alveolar bone (21025, 21030, 41874, 21215, 21248, 21079 and 21085) have not been met. 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. Specifically, the services are not listed in the Plan's 2020 benefit chart making them non-covered services. Therefore, we decided that the Plan does not have to pre-approve osseous surgery and bone grafting of the alveolar bone (21025, 21030, 41874, 21215, 21248, 21079 and 21085).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Binocular microscopy (92504) provided
August 25, 2020, and September 8, 2020.
You asked the Plan to waive the copayment for Binocular microscopy. You say that the copayment for these
services should be waived. The Plan denied your request. The Plan says the copayments were applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25
copayment for Medicare-covered non-radiological diagnostic services. In addition, the Plan issued a copayment
waiver for covered primary care provider (PCP) and specialist physician services, as well as other covered
services specialist between May 11, 2020, and September 30, 2020. The copayment waiver states that your
cost-share is not waived for Lab and Diagnostic tests (radiological and non-radiological) unless they are related
to COVID-19 testing or treatments.
You have been asked to pay a total of $50 copayment for Binocular microscopy. Binocular microscopy falls
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 Binocular microscopy (92504) provided August 25, 2020, and
September 8, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan does not have to pay forgenetic testing provided to the enrollee on June 11, 2020.You asked the Plan to pay forthis service. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says these services were not provided by a Medicare eligible provider. Maximus overturned the Plans denial stating the services were ordered by your physician and should be paid. The Plan requested a reopen and stated that any service provided to a Medicare beneficiary that is non emergent cannot be paid when rendered bya provider who is not eligible to accept Medicare payment.The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program or who is not eligible to accept Medicare payment structures. This was outpatient lab testing, which requires prior authorization both in and out of network. The enrollee did not have prior authorization for this testing and the provider is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay forgenetic testing provided to the enrollee on June 11, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that the enrollee needs oxygen level adjustments. The Plan denied your request. The Plan says the enrollee's needs are custodial.
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 services. Our physician reviewer found that the enrollee does not have any parental medication, complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or near baseline. Supplemental oxygen is not considered skilled care, and she can be monitored at a custodial level of care. Therefore an admission to a SNF for inpatient skilled care is not medically necessary. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor the removal of the tunneled central venous access device (36590) provided on September 16, 2020.You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.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 $100 per day for outpatient procedures and services, including, but not limited to, outpatient surgery performed in an outpatient hospital or ambulatory surgical center. You have been asked to pay a $100 copayment for the outpatient surgery provided. 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 copaymentfor the removal of the tunneled central venous access device (36590) provided on September 16, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foracoustic reflex decay testing (92567) and comprehensive audiometry threshold evaluation and speech recognition test (92557) provided November 4, 2020.You asked the Plan to waive the copayment forthe diagnostic hearing tests. You say that you thought that the services were free with the plan. You could have goneto CVS and got a free diagnostic hearing exam.The Plan denied your request. The Plan says the claim was processed and the correct copayment was 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 $45 copay for diagnostic hearing exams. You have been asked to pay $43.32 copay for the diagnostic hearing tests. Due to the allowed amount, the amount due to the provider is $43.32 instead of the $45. the diagnostic hearing tests falls within the Hearing 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 foracoustic reflex decay testing (92567) and comprehensive audiometry threshold evaluation and speech recognition test (92557) provided November 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe provided knee orthosis (L1852) and addition to lower extremity orthotic (L2397).You asked the Plan to pay forthe provided knee orthosis (L1852) and addition to lower extremity orthotic (L2397). You say that the provided knee orthosis (L1852) and addition to lower extremity orthotic (L2397) was medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the provided knee orthosis (L1852) and addition to lower extremity orthotic (L2397).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 pay for the provided knee orthosis (L1852) and addition to lower extremity orthotic (L2397). Our reviewer says that the enrollee does not meet criteria for the provided knee orthosis (L1852) and addition to lower extremity orthotic (L2397). Our physician reviewer found the enrollee received a knee orthosis and addition on August 18, 2020. The enrollee has had knee pain for years. Criteria for the knee brace have not been met. There is no instability, fracture, or deformity. The knee brace is not medically needed for degenerative knee pain.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 provided knee orthosis (L1852) and addition to lower extremity orthotic (L2397) have not been met.Therefore, we decided that the Plan does not have to pay forthe provided knee orthosis (L1852) and addition to lower extremity orthotic (L2397)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvebone marrow aspiration for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysexperimental and investigational services are not covered.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 services. Our reviewer says that the requestedservices are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee complained of chronic lower back pain with pain in the right lower extremity.  A request for L3-S1 posterior decompression and fusion with TLI F in addition to sacroiliac joint fusion was submitted.  The requested lumbar interbody fusion surgery was certified.  However, thebone marrow aspirate and sacroiliac joint fusion were denied.  The rationale was that there were no clinical findings on MRI of any sacroiliac joint involvement.  The MRI dated 05/26/2020 revealed that the sacrum and SI joints were unremarkable.  The provider stated in his appeal letter that the physical therapist stated that the enrollee is not a good candidate for therapy.  However, the 12/30/2020 physical therapy evaluation recommended physical therapy (and did state that there was a concern of spinal instability and a fall risk). Overall, there was no detailed discussion of any significant sacroiliac joint involvement. Considering the absence of any significant involvement of the sacroiliac joint; the requested bone marrow aspirate and SI joint fusion is not reasonable or necessary.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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvebone marrow aspiration for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetwo gingival irrigations.You asked the Plan to pre-approvethe gingival irrigations. The Plan deniedyour request. The Plan says this service is not a covered 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.Therefore, we decided that the Plan does not have to pre-approvetwo gingival irrigations
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 10, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis whiletemporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on September 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient services provided from June 6, 2020 to June 10, 2020.
You asked the Plan to waive the copayment for the inpatient services. You say that you cannot afford the copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $393 copayment each day for days 1-5 for Inpatient Hospital Care. You have been asked to pay a $393 copayment each day for days 1-4 for the inpatient services. The inpatient services fall within the Inpatient Hospital Care 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 inpatient services provided from June 6, 2020 to June 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral for dental services (D6056, D7140, D6010) with an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested dentist is not in the plan's 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 theitems/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 Plandoes not haveto pre-approvea referral for dental services (D6056, D7140, D6010) with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you have a limb length difference which affects your gait.The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy rendered from April 29, 2020 to August 5, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy rendered from April 29, 2020 to August 5, 2020.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral for dental services (D6903, D5875, D0220, D6118) with an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a 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 Plandoes not haveto pre-approvea referral for dental services (D6903, D5875, D0220, D6118) with an out-of-network provider.