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

We decided that the Plan does not have to waive the cost for the PET scan and Fluciclovine.

You asked the Plan to waive the cost for the PET scan and Fluciclovine. You say that you should not be responsible for anything other than the copayment for the scan. You say that the cost of the Fluciclovine should be part of the radiological diagnostic benefit. The Plan denied your request. The Plan says the cost share 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 $110 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility and 20% coinsurance for each Medicare-covered medical supply.

You have been asked to pay a total of $1,068.80 for the PET scan and Fluciclovine.

The PET scan and Fluciclovine fall 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 cost for the PET scan and Fluciclovine.
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 services. You say that you have never been informed by the plan that this specific code has a frequency limit of once every 3 years. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit 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 of once every 3 plan years has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical, occupational, and speech therapy.
You asked the Plan to pre-approve physical, occupational, and speech therapy. You say that this is medically necessary. The Plan denied your request. The Plan says you have refused to participate in therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical, occupational, and speech therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you have had prior therapy with reluctance to participate and continue to refuse to get out of bed. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment. The requested services are not part of a maintenance program required to establish, design, or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical, occupational, and speech therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve physical, occupational, and speech therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the power wheelchair seat elevation system.

You asked the Plan to reimburse you for the power wheelchair seat elevation system. You say that the power seat elevation system is medically necessary for your safe and independent functioning in your home. The Plan denied your request. The Plan says power seat elevation systems are not covered by Medicare or the Plan.

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 reimburse you for the power wheelchair seat elevation system.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045).

You asked the Plan to pay for the chest x-ray. You say that the services were medically necessary. The Plan denied your request. The Plan says this service shares a column I / column II relationship with another service billed and is not eligible for separate payment.

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 have confirmed that code 71045 has a column I / column II relationship with code 74022 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that all services that would be provided in the LTACH are being provided in the current acute care 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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided from August 13, 2020, to August 20, 2020.
You asked the Plan to pay for acupuncture. You say that the provider told you that your insurance covered this acupuncture. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is not eligible to perform these services and is not covered.
The Plan must follow Medicare rules. The rules say that acupuncture may be covered under certain circumstances when provided by a physician, physician assistant, nurse practitioner, clinical nurse specialist, or auxiliary personnel furnishing acupuncture under the appropriate level of supervision. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, a licensed acupuncturist is not among the provider types for which acupuncture may be covered by Medicare. Therefore, we decided that the Plan does not have to pay for acupuncture services provided from August 13, 2020, to August 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test provided by an out-of-network provider on January 7, 2020.
You asked the Plan to pay for the drug test. You say that the claim should be reprocessed. The Plan denied your request. The Plan says there were network providers available to perform the services.
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 drug test provided by an out-of-network provider on January 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brain imaging, positron emission tomography (PET).
You asked the Plan to pre-approve the brain PET scan. You say that this enrollee's symptoms are worsening, and you need this imaging study for further evaluation in order to properly treat this enrollee. The Plan denied your request. The Plan says the procedure is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET 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 the brain PET scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the enrollee is noted to have a palpable mass. However, she is not noted to have undergone a biopsy to confirm that the mass is a tumor. There was no indication of any other diagnostic testing having been completed to date to suggest that the member has a tumor either. Therefore, it cannot be said that the requested PET/CT scan would be conducted in accordance with the requirements of the NCD for coverage of this service. Furthermore, for MRI of the brain, Medicare only covers this service in the evaluation of dementia (when additional requirements are met). The provider int his case has ordered a PET scan to evaluate the enrollee's basal ganglia. This is not an indication for which Medicare supports the use of PET scan of the brain. For these reasons the requested PET/CT scan would not be reasonable and 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 brain PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve Brain imaging, positron emission tomography (PET).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stairway elevator.
You asked the Plan to pre-approve the elevator. You say that this is medically necessary. The Plan denied your request. The Plan says this does not serve a primarily and customarily medical purpose.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stairway elevator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on October 26, 2020.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says that the Plan does not provide coverage for services received from out-of-network providers, except emergency, urgently needed services, and end-stage renal disease services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for diagnostic radiology services provided on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit.

You asked the Plan to waive the copayment for the specialist office visit. You say that there should be no copayment for this post-op appointment. The Plan denied your request. The Plan says you have been asked to pay 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 $40 copayment for each in-network Medicare-covered visit with a specialist.

You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which states a copayment would be waived for a surgical follow-up 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 specialist office visit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening digital breast tomosynthesis (77063) and screening mammography (77067).

You asked the Plan to pay for the tomosynthesis and mammography. You say that you would like reconsideration because the right to recover for services provided to eligible beneficiaries is not extinguished by specific Plan requirements. The Plan denied your request. The Plan says this claim was not billed with the required revenue code.

The Plan must follow Medicare rules. Medicare rules say that all charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue code 0510.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tomosynthesis and mammography have not been met. Specifically, this claim was not billed with the appropriate revenue code. Therefore, we decided that the Plan does not have to pay for the screening digital breast tomosynthesis (77063) and screening mammography (77067).
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.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee could be treated at a lower level of care.

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 enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met at a lower level 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 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 18, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you have an HMO Plan with no out-of-network coverage except for urgent/emergent services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on November 18, 2020.
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.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan denied your request. The Plan says you can safely receive the services you need 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. Our physician reviewer found there are no complex nursing or rehabilitation needs and there is no documented need for intensive rehabilitation 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 IRF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth number 4 and core build up (D2950) for tooth numbers 3 and 14.

You asked the Plan to these dental services. You say that these services are medically necessary. The Plan denied your request. The Plan says the crown benefit is not currently available and core build up is not covered under the dental benefit at all. Maximus agreed with the Plan regarding the core build up but indicated the Plan had approved the crown. The Plan requested a reopen and stated that Maximus did not interpret the case correctly. 

The Plan is correct in this case. 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 contract says that crowns are covered every 60 months. The records show the Plan paid for a crown in 2019, therefore that service is not currently available. The Plan contract also states that core build up is not a covered benefit. Therefore, we have now decided that the Plan does not have to pre-approve a crown (D2740) for tooth number 14 and core build up (D2950) for tooth numbers 3 and 14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) provided on May 27, 2020.
You asked the Plan to pay for the dental service. You say that the service was denied under your dental policy. You say that you were advised to submit the claim under your medical plan. You also say that the service should be covered. The Plan denied your request. The Plan says the service you received is dental in nature. The Plan also says that the dental service is not covered under Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. 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 pay for the incisional biopsy of oral tissue (D7286) provided on May 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says the care can be received in another setting, such as home, a long-term care facility,
or other outpatient setting.
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 the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility
setting.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.