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

We decided that the Plan does not have to waive the cost share for the duplex scan provided on October 9, 2019.
You asked the Plan to waive the cost share for the duplex scan. You say that you would like to appeal this claim. 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. Your contract with the Plan says that there is a $300 combined deductible that applies towards out-of-network outpatient radiology services and a $100 copayment for each out-of-network Medicare-covered radiological diagnostic service, not including x-rays. The duplex scan you asked the Plan to waive the cost share for falls within the "Outpatient diagnostic tests and therapeutic services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 combined deductible that applies towards out-of-network outpatient radiology services and a $100 copayment for each out-of-network Medicare-covered radiological diagnostic service, not including x-rays. See chart below.
Date of Service
Service
Allowed Amount
Deductible/Copayment
Member Liability
October 9, 2019
Duplex scan
$234.20
$300
$138.60 - This is where you met your combined deductible amount.
$95.60 - This is the remaining allowed amount ($234.20 - $138.60)
$100
$95.60
Total
$234.20
This cost sharing is a contractual obligation that had not been met at the time the duplex scan was received on October 9, 2019. Therefore, we decided that the Plan does not have to waive the cost share for the duplex scan provided on October 9, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve SpaceOAR hydrogel perirectal spacer.
You asked the Plan to pre-approve the SpaceOAR hydrogel spacer. You say that this should be allowed to reduce the radiation dose to the rectum. The Plan denied your request. The Plan says that this is not proven effective for those with high-risk prostate cancer.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 the SpaceOAR hydrogel spacer. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found SpaceOAR is a hydrogel spacer inserted between the rectum and prostate in order to reduce the dose exposure of the rectum- and thus rectal toxicity - in men undergoing radiation for prostate cancer. A prospective multicenter randomized controlled trial (Mariados N et al.) studying this spacer was published in 2015. The authors concluded: "Increased perirectal space reduced rectal irradiation, reduced rectal toxicity severity, and decreased rates of patients experiencing declines in bowel quality of life. The spacer appears to be an effective tool, potentially enabling advanced prostate RT protocols." Yet another analysis of this study (Hamstra et al., 2018) showed that SpaceOAR "decreased dose to the penile bulb, which was associated with improved erectile function compared with the control group based on patient-reported sexual QOL" All of these studies report that the spacer placement is well tolerated and results on low rates of rectal toxicity. These results are unsurprising as the hydrogel spacer essentially places the rectum outside of the high dose radiation field. Conceptually its use makes sense and the published data support its tolerability and efficacy. The use of a hydrogel spacer can be considered medically necessary when justified for patients with high risk disease, acknowledging that the level 1 data did not include these patients, meeting the standard coverage criteria, as its use would be furnished in accordance with accepted standards of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SpaceOAR hydrogel spacer have been met. Therefore, we decided that the Plan has to pre-approve SpaceOAR hydrogel perirectal spacer.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for custom molded shoes and inserts provided on December 17, 2019.
You asked the Plan to pay for foot orthotics. You say that you are requesting reimbursement of services rendered. 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 pay for custom molded shoes and inserts provided on December 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new power wheelchair.
You asked the Plan to pre-approve the power wheelchair. You say that you require this wheelchair. The Plan
denied your request. The Plan says this is not required for use within the home. This means it is not covered by
Medicare.
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.
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs within the
home. The documentation shows that this is requested for use in your apartment building and outside the
home.. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that
the Plan does not have to pre-approve a new power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve (E0978), (E2613), (K0108), (K0040) and (K0038), for the enrollee.
You asked the Plan to pre-approve the items. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
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. Angle adjustable footplate is included in the allowance for the ultralight weight manual wheelchair (Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504), the leg strap and wheelchair component or accessory, not otherwise specified (plastic side guard) do not primarily serve a medical purpose and are convenience items. The member does not have a qualifying diagnosis for the positioning wheelchair back cushion (per the Wheelchair Seating - Policy Article (A52505). There is no evidence of trunk weakness or
postural instability or muscle spasticity therefore the medical necessity criteria for the positioning belt/safety belt/pelvic straps not established based on (LCD): Wheelchair Options/Accessories (L33792). Therefore, we decided that the Plan does not have to pre-approve (E0978), (E2613), (K0108), (K0040) and (K0038), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to, an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are other network providers available.
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 a referral to an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient stay provided from February 6, 2020 to February 11, 2020.You asked the Plan to waive the copayment for an inpatient stay. You say that due to the quality of care the enrollee should not be responsible for the charges.The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $220 copayment per day for days 1-5 for inpatient hospital care. The enrollee had an inpatient hospital stay from February 6, 2020 to February 11, 2020. Therefore, they are responsible to pay a $220 copayment for days 1-5 (February 6, 2020 to February 10, 2020). $220 (copayment) x 5 (inpatient days) = $1,100.The enrollee has been asked to pay the total copayment amount of $1,100 for inpatient stay. An inpatient stay falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran inpatient stay provided from February 6, 2020 to February 11, 2020.Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 2, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The
Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital
setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) having
been admitted for a redo sternotomy and valve revisions. The enrollee's post-operative course had been
complicated by valve leak, cardiogenic shock, respiratory failure, pancreatitis and a colonic abscess. The
enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee does not yet appear
stable for ventilator weaning or LTACH transfer. The enrollee can remain at the current ACH for ongoing
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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a complex cystometrogram provided by a participating facility foundation on November 1, 2019.You asked the Plan to waive the copayment for a complex cystometrogram. You say that this was a diagnostic test to see if you needed a sling on your bladder. The Plan denied your request. The Plan says the correct copayment has been applied.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 $295 copayment for outpatient surgery. You have been asked to pay a $295 copayment for a complex cystometrogram. The procedure that was provided is considered an outpatient surgery. A complex cystometrogram falls within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a complex cystometrogram provided by a participating provider foundation on November 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex spacer.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.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 services are not medically necessary. Our physician reviewer found the enrollee has complaints of dominantly axial low back pain with signs/symptoms consistent with neurogenic claudication. The requested Vertiflex spacer is not considered the standard of care. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. The services are therefore not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a Vertiflex spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on October 23, 2019 from an out-of-network provider.
You asked the Plan to pay for the hearing aids. You say that this provider is better than the other providers. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Review of the file show that you purchased hearing aids on October 23, 2019 from an out-of-network provider. The provider is not in-network and your EOC states, there is a $1000 allowance toward the purchase price of hearing aid(s) every 36 months when prescribed by a Plan physician or by a Plan Provider who is an audiologist. Therefore, we decided that the Plan does not have to pay for hearing aids purchased on October 23, 2019 from an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient facility services provided from August 13, 2019 to August 20, 2019.
You asked the Plan to pay for the inpatient facility services. You say that the claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the inpatient facility services provided from August 13, 2019 to August 20, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a sleep study provided on August 27, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for a sleep study. You say that you would like this claim reprocessed and approved
for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The 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. 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 a sleep study provided on August 27, 2019 by an
out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for Tooth #13.
You asked the Plan to pre-approve the crown. You say that the crown is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that the crown is not medically necessary at this time. Our physician reviewer found due to the lack of significant coronal breakdown of tooth #13, the crown is not indicated. 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 the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for Tooth #13.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for CT scan of the head and neck at an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is no identified need for the imaging to be done at the out of network site.
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 a referral for CT scan at an out-of-network provider.