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

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and core buildup, including any pins when required.

You asked the Plan to pay for the first intraoral periapical x-ray and core buildup. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you signed a financial agreement with the office, prior to services being rendered.

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 pay for the first intraoral periapical x-ray and core buildup, including any pins when required.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology consultation during surgery (88239).

You asked the Plan to pay for the surgery services. You say that you relied on the information from the doctor's office, the plan and the hospital to make certain nothing was performed that was not covered by the insurance. Please review all the facts and approve the full payment of these claims. The Plan denied your request. The Plan says this is a duplicate of a charge considered on a previous claim.

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, we find that CPT code 88239 is a duplicate service of a charge considered on a previous claim, submitted by another provider for the same date of service. Based on this information, we decided that Medicare rules for coverage of the outpatient surgery services have not been met. Therefore, we decided that the Plan does not have to pay for the pathology consultation during surgery (88239).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided by an out of network (OON) provider.

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 the services were rendered by an out-of-network provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the physician services provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology service (88304) provided by an out of network (OON) provider.

You asked the Plan to pay for the pathology service. You say that you will look into getting the referral from your primary care provider. The Plan denied your request. The Plan says they only cover out of network services in limited circumstances. The service provided was not urgent or pre-approved. No referral was received.

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. No referral was submitted for review. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the pathology service (88304) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider.

You asked the Plan to pay for the office visit. You say that the documentation supports medical necessity. You say that payment for the claim should be reconsidered. The Plan denied your request. The Plan says services should be received from network providers.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. 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. 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 for the ambulance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammogram provided by an out-of-network provider.

You asked the Plan to pay for the mammogram. You say that the claim has not been paid in full or under the terms of the contract. You say that payment should be made. The Plan denied your request. The Plan says this provider is not a network provider with 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the mammogram provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the services the enrollee requires cannot be safely met with home health services or a skilled nursing facility at this time. The Plan denied your request. The Plan says this request is 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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee 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. Medically necessary care can be provided in a different level of care. Our physician reviewer also found that there is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Wrangler scooter for the enrollee.

You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says this is primarily for outside use.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found the enrollee's mobility deficit is currently helped by a manual wheelchair in the home. The requested Wrangler would not be safe or functional for in-home use and is therefore 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 the scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a Wrangler scooter for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nuclear medicine.

You asked the Plan to waive the copayment for nuclear medicine. You say that the charges are too high. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $300 copayment for advanced imaging and nuclear medicine.

You have been asked to pay a $300 copayment for nuclear medicine. Nuclear medicine 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 nuclear medicine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150).

You asked the Plan to pay for the dental service. You say that the benefit book says that you can have your teeth cleaned twice per year. You say that this is the first time that you have had your teeth cleaned this year. You say that any other work that you have had done has not been done since 2018. You also say that you do not understand why the service was not covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that the frequency limit for this service 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 this service has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received less than 3 years ago. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150).
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 a standard home blood glucose monitor appears appropriate.

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 services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that in this case, the enrollee is not receiving insulin. The required elements of the controlling rules are
not satisfied. Therefore, the recommended service cannot be recommended.

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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve the SNF care.

You asked the Plan to pre-approve SNF care. You say that admission to the SNF is necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet Medicare guidelines for services provided in a SNF.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the enrollee qualifies for SNF coverage. Our physician reviewer found the enrollee does have documented skilled nursing needs. Monitoring of her cardiovascular status following recent valve surgery, repeated admissions and medication adjustments is medically necessary and reasonable. Our reviewer found that the enrollee does have documented skilled therapy needs. While the enrollee is ambulatory, she exhibits fatigue and would benefit from endurance and strength training. Our physician reviewer also found that daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must cover the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve the SNF care.

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 the laboratory services.

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 the services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: Practitioner Services
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 behavioral health services (99214). You say that you would like reconsideration because you have received care from this provider in the past without issue. The Plan denied your request. The Plan says permission was not asked prior to services being performed.
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 where prior authorization is obtained. The requested provider in this case is not a network provider with the Plan. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a recreational vehicle (RV).

You asked the Plan to pay for a recreational vehicle. You say that renting an RV was the only safe way to return home. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for a recreational vehicle (RV).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMems device for the enrollee.

You asked the Plan to pre-approve the CardioMems device. You say that the CardioMems device is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical director looked at the case file and the reopen request. At issue is coverage for the CardioMems device. The Maximus Physician Reviewer determined that better day-to-day assessment of the exact state of the enrollee's cardiac filling pressures would be medically useful to more carefully titrate diuretics and other cardiac medications for blood pressure and fluid control while hopefully improving his renal function. CardioMems device would allow this closer titration of his volume status (which appears very difficult to assess clinically or by non-invasive means like weights) and is indicated for use in this clinical situation. It is FDA-approved for this purpose, has randomized published data to support its use, would not be considered investigational and is medically necessary in this patient per Medicare rules. The Plan argues that the enrollee is not participating in a Medicare-approved IDA clinical study. The medical records show the enrollee is a 60-year-old man with a diagnosis of Unspecified diastolic (congestive) heart failure, as well as stroke, hypertension, and hyperlipidemia. Our Medical Director has concluded that the Plan is correct in this case, as the enrollee is not enrolled in a Medicare-approved IDA clinical study. 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 CardioMems device have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMems device for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia. You say that you recommend the enrollee begin treatment with Prolia as soon as possible. The Plan denied your request. The Plan says the enrollee did not try any of the preferred drugs to treat osteoporosis first.

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 Prolia. Our reviewer says that Prolia (J0897) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drug Zoledronic acid or brand name Reclast before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drug(s) 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).