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

We decided that the Plan does not have to pay for the medical services provided on September 10, 2019 to November 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for ophthalmology services. You say that prior to these services you were informed by the provider that they were contracted with your insurance. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and you could have received these services from an in-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 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 the medical services provided on September 10, 2019 to November 5, 2019 by an out of network (OON) provider.
Your complaint regarding receiving inaccurate information about the network status of this provider is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity.
You asked the Plan to pre-approve Trulicity. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Trulicity is not covered under the enrollee's Medicare Part B 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 Trulicity.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on August 18, 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 you by an out-of-network provider on August 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve focal prostate ablation.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 records show that you have a diagnosis of prostate cancer treated with radiotherapy in 2004. MRI-guided focal laser ablation for the treatment (primary or salvage therapy) of prostate cancer is considered experimental and investigational because its effectiveness has not been established.The American Urological Association (AUA) and National Comprehensive Cancer Network (NCCN) guidelines for treatment of localized prostate cancer do not mention this as a treatment option. The requested focal prostate ablation is 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-approvefocal prostate ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device for the enrollee.You asked the Plan to pre-approve these services. You say that the CardioMEMS device will help you better monitor the member's condition and symptoms.The Plan denied your request. The Plan says that Medicare coverage criteria has not been met since the device is considered experimental/investigational.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that a CardioMEMS device is not medically reasonable and necessary for the enrollee in this case. In this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Our physician reviewer found that Medicare coverage criteria have not been met since the device should still be considered experimental or investigational.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 CardioMEMS device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for Radiation oncology services (77427, G6015, 77014, 77300, 77336) provided January 31, 2019 to February 13, 2019.You asked the Plan to waive the copayments forthe radiation oncology services. You say that the out-of-pocket maximum was met and the cost share should be waived.The Plan denied your request. The Plan says the correct cost sharing was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a 30% coinsurance for Radiation Therapy. The enrollee has been asked to pay a 30% coinsurance for the radiation oncology services. The radiation oncology services fall within the Radiation Therapy benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. The Member Benefit Ledger provided by the health plan shows that the enrollee's out of pocket maximum was not met at the time services were provided. 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 copayments forRadiation oncology services (77427, G6015, 77014, 77300, 77336) provided January 31, 2019 to February 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe implant placements (D6010) for teeth # 23 and 26.You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says implants are 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, implants are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe implant placements (D6010) for teeth # 23 and 26
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for home health services (G00151, Q5001, G0300, and G0299) provided from June 11, 2019 to June 24, 2019.
You asked the Plan to pay for home health services. You say that these services were authorized and properly billed. The Plan denied your request. The Plan says that this claim is missing a treatment authorization code.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the treatment authorization code on the corrected claim appears to be in a valid format. The Plan has not provided any information about why it is not valid. It is the burden of the Medicare Health plan to substantiate the denial. The denial is not substantiated, and we must find in your favor. Therefore, we decided that the Plan has to pay for home health services (G00151, Q5001, G0300, and G0299) provided from June 11, 2019 to June 24, 2019.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (97032) provided on April 18, 2019.
You asked the Plan to pay for electrical stimulation. You say that this should be paid. The Plan denied your request. The Plan says this treatment remains unproven.
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 electrical stimulation. Our reviewer says that the services at issue are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is noted to be three weeks status post right foot surgery. The documentation states that the patient is healing and progressing within normal limits for the postoperative timeframe. There is no comorbidity stated in the progress note that would allow for diminished healing. Therefore, the use of the H wave electrical stimulation is not medically reasonable or necessary for this patient. It does not appear to be within the accepted standards of medical practice for a healthy patient who is healing without difficulty. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of electrical stimulation have not been met. Therefore, we decided that the Plan does not have to pay for electrical stimulation (97032) provided on April 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the Cervical Spine (72141)You asked the Plan to pre-approvethe MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says rules for coverage of the MRI have not been met.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that coverage criteria has not been met. Our physician reviewer found there are no reported neurological abnormalities on exam.  The clinical information received fails to support the need for an MRI at this time.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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the Cervical Spine (72141).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe seat lift mechanism of a seat lift recliner.You asked the Plan to pre-approvethe seat lift mechanism. You say that the enrollee needs assistance to stand.The Plan denied your request. The Plan says they requested but did not receive clinical documentation from the enrollee's physician supporting medical necessity of a seat lift mechanism.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. Medicare does not cover the upholstered portion of a seat lift recliner.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism have not been met.Therefore, we decided that the Plan does not have to pre-approvethe seat lift mechanism of a seat lift recliner.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the crown (D2750) and the 2 unspecified adjunctive procedures (D9999) provided on July 31, 2019.
You asked the Plan to reimburse you for the crown and the 2 unspecified adjunctive procedures. You say that you slipped on a ladder and hit your mouth on a ladder rung. You say that you broke your 3 crown bridge and cracked the tooth underneath. You say that this should be covered under your health insurance because it was by accident and not caused by biting into something. The Plan denied your request. The Plan says the maximum benefit has been reached.
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 unspecified adjunctive procedure is not among those covered under this benefit. Additionally, the services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the crown (D2750) and the 2 unspecified adjunctive procedures (D9999) provided on July 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Upper Extremity (73221).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says the records do not support that the MRI is medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that coverage criteria hasn't been met. Our physician reviewer found there is no documentation of wrist or shoulder pain refractory to conservative treatment. There is no documentation of injury or concerning physical exam findings. The available clinical documentation does not support medical necessity for requested MRI of wrist and shoulder at this time. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Upper Extremity (73221).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the upper partial denture (D5213) and the lower partial denture (D5214) provided on October 1, 2019.You asked the Plan to pay forthe dental services. You say that you received a bill that included upper and lower dentures. You say that you did not receive dentures. You also say that you advised that you did not want any services that would not be covered by your insurance.The Plan denied your request. The Plan says the frequency limit has been exceeded.Medicare generally does not cover dental services. However, the Plan offers adental 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 and the partial dentures you received are listed as a covered services, the frequency limit has been exceeded. The records shows that the Plan previously paid for the partial dentures that you received on March 12, 2019.Therefore, we decided that the Plan does not have to pay forthe upper partial denture (D5213) and the lower partial denture (D5214) provided on October 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the wound care provided from September 9, 2019 to September 30, 2019.
You asked the Plan to waive the copayments for the wound care. You say that you were told you would only have to pay the copayments for the wound care services. You say insurance did not pay anything. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for surgery services at an in-network outpatient hospital. For each date of service, you have been asked to pay the allowed amount of the claim because these amounts are less than the $250 copayment for wound care visits in an outpatient hospital.
You have been asked to pay a total of $613.45 copayment for the wound care. The wound care falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Copayment
Member Liability
September 9, 2019
Wound care
$234.82
$250.00
$234.82
September 16, 2019
Wound care
$126.21
$250.00
$126.21
September 23, 2019
Wound care
$126.21
$250.00
$126.21
September 30, 2019
Wound care
$126.21
$250.00
$126.21
Total
$613.45
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 copayments for the wound care provided from September 9, 2019 to September 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scans of the chest and abdomen/pelvis for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of stage IIA malignant melanoma of the right upper extremity. The provider notes dated December 19, 2019 outline a plan for CT imaging every six months. Advanced imaging screening every six months for this diagnosis is not the standard of care and is not reasonable or medically necessary at this time. 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 computed tomography (CT) scans of the chest and abdomen/pelvis for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab services provided on October 23, 2019 by an out of network (OON) provider.You asked the Plan to pay for outpatient lab services. You say that you provided the tests that were requested from the referring  provider. You say that you do not see the patient.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained for these tests.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-networkproviders 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 foroutpatient lab services provided on October 23, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (L1851 and L2397) provided on September 11, 2019.
You asked the Plan to pay for the durable medical equipment. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (L1851 and L2397) provided on September 11, 2019.