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

We decided that the Plan does not have to pre-approve crowns (D2740), core buildup (D2950), debridement (D4355), and precision attachments (D6950).
You asked the Plan to pre-approve crowns, core buildup, debridement, and precision attachments. You say that you need these services because you are not able to chew or eat. The Plan denied your request. The Plan says these services are not covered.
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-approve crowns (D2740), core buildup (D2950), debridement (D4355), and precision attachments (D6950).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 17, 2020.
You asked the Plan to waive the copayment for the office visit. You say that this was your annual diabetic check-up. You say that your previous annual visits were $0, and the copayment should be refunded. The Plan denied your request. The Plan says the copayment 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 $35 copayment for each Medicare-covered specialist visit. You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/practitioner services, including doctor's office visits" benefit category. The records show you were treated for cataracts during the office visit. 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 the office visit provided on November 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the lower extremity.
You asked the Plan to pre-approve an MRI of the lower extremity. You say that the requested MRI of the lower extremity is medically necessary. The Plan denied your request. The Plan says the requested MRI of the lower extremity is not 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 an MRI of the lower extremity. Our reviewer says that the requested MRI of the lower extremity is not medically necessary. Our physician reviewer found the enrollee is with a history of systemic lupus erythematosus (SLE) and osteoporosis complaining of severe joint pain and swelling of the knee. Criteria for MRI of the knee are not met. There is no documentation of a physical exam. More information is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the lower extremity have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI of the lower extremity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) for teeth # 15, 19, and 21.
You asked the Plan to pre-approve the dental services. You say that the enrollee wants his to save his own teeth. The Plan denied your request. The Plan says localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The Customer Handbook clearly states that if a dental item or service is not listed in the benefit chart, then it is not covered. Therefore, we decided that the Plan does not have to pre-approve localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) for teeth # 15, 19, and 21.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COVID !9 pneumonia and has been discharged to a skilled nursing facility. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 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. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 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 a history of lumbar pain. Open laminectomy is the gold standard for spinal stenosis decompression. The Vertiflex Superion spacer is experimental, as more research is needed to show safety and efficacy of the spacer. 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 Superion spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on July 27, 2020.
You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says the services were not referred by a network provider or rendered in a participating facility. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 did not pre-approve the ophthalmological 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 ophthalmological services provided on
July 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services. You asked the Plan to pay for the dental services. You say that no dentists were listed in the 2020 provider directory. The Plan denied your request. The Plan says this provider has opted out of Medicare. 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 services you are asking the Plan to pay for involve care provided by a provider who has opted out of Original Medicare. Therefore, we decided that the Plan does not have to pay for the dental services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for spirometry provided on October 21, 2020.
You asked the Plan to waive the copayment for spirometry. You say that this was an annual wellness visit and you should not owe a copayment. 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 $20 copayment for outpatient diagnostic tests. You received spirometry on October 21, 2020. Spirometry is not included in annual wellness exams. Therefore, you are responsible to pay the $20 copayment. You have been asked to pay a $20 copayment for spirometry. Spirometry 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 spirometry provided on October 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the OneOme RightMed pharmacogenomics test provided on October 9, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the case file contains the results of a OneOme RightMed Gene Report. There are no clinical medical records in the case file. There is insufficient clinical documentation to demonstrate that OneOme RightMed pharmacogenomics testing was medically reasonable and necessary for the enrollee in this case. 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 testing have not been met. Please note that the local coverage article referenced by the Plan is not applicable for the jurisdiction in question. Therefore, we decided that the Plan does not have to pay for the OneOme RightMed pharmacogenomics test provided on October 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on October 13, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that someone from your primary care physician's office ordered the wrong bloodwork without her permission. The Plan denied your request. The Plan says the copayment 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 $20 copayment for lab services performed by a provider other than your primary care physician. You have been asked to pay $10.56, which is less than the standard $20 copayment for the laboratory services. Laboratory services falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the laboratory services were billed by the hospital. 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 laboratory services provided on October 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the air ambulance transport provided on September 17, 2020.
You asked the Plan to waive the coinsurance for the air ambulance transport. You say that the EMS could have driven you to the hospital and it would have been covered under one copayment. You say that you don't think you owe the bill for the airlift charges. The Plan denied your request. The Plan says the coinsurance 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 20% of the Medicare-allowed amount per one-way trip for air ambulance. You have been asked to pay $1,613.43, which is 20% of the allowed amount for the air ambulance transport. The allowed amount is $8,067.15 (20% x $8,067.15 = $1,613.43). The air ambulance transport falls within the "Ambulance services" benefit category. The records show you were transported by air to the hospital. 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 coinsurance for the air ambulance transport provided on September 17, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on August 4, 2020.
You asked the Plan to pay for lab testing. You say that you are appealing this denial. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels.
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering provider was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for laboratory testing provided on August 4, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy visit provided on October 5, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy visit. You say that the services were medically necessary. 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 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 psychotherapy visit provided on October 5, 2020 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 computerized corneal topography provided on August 21, 2020.
You asked the Plan to pay for the computerized corneal topography. The Plan denied your request. The Plan says this is 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 pay for the computerized corneal topography. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the medical records indicate that the requested service is for routine preoperative assessment of cataract surgery. The medical reasonableness and necessity of the requested service has not been established. Therefore, the requested 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 computerized corneal topography have not been met. Therefore, we decided that the Plan does not have to pay for the computerized corneal topography provided on August 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gingival irrigation service (D4921).
You asked the Plan to pre-approve the gingival irrigation. You say that this service is necessary. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental 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-approve a gingival irrigation service (D4921).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for arthrocentesis services provided out of area on October 19, 2020.
You asked the Plan to pay for the out of area arthrocentesis services. You say that you were bleeding and had to see a doctor. You say that, due to COVID and being at high risk, you could not fly home to see an in-network doctor. The Plan denied your request. The Plan says that the services in dispute were not urgent or emergent, nor were they approved in advance.
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 Plan has not provided us with any medical records or evidence of having made reasonable attempts to obtain medical records. Without this information, the Plan has not substantiated their denial reason that the services were not urgent or emergent. The Plan has not provided us the information needed to support that the services performed out of area could have been delayed until the enrollee returned to the service area. Therefore, we decided that the Plan has to pay for arthrocentesis services provided out of area on October 19, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided by an opted-out physician on November 3, 2020.
You asked the Plan to pay for office visit. You say that you have seen this provider in the past, and because you did not get a copy of the 2020 Evidence of Coverage (EOC) for this Plan this should be processed through your out-of-network benefits. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider has opted out of Medicare coverage and is not payable. 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 except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office visit provided by an opted-out physician on November 3, 2020. Your complaint regarding not receiving a copy of the Plan's 2020 Evidence of Coverage 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.