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

We decided that the Plan does not have to pre-approve laboratory services (84100, 84443, 85025, 82728, 83036, 83540, 83735, 84439, 84480 and 87899) provided on February 11, 2020.
You asked the Plan to pre-approve the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services were rendered for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.
The test at issue in this appeal, the laboratory services, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve laboratory services (84100, 84443, 85025, 82728, 83036, 83540, 83735, 84439, 84480 and 87899) provided on February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic casts (D0470) provided on June 4, 2020.
You asked the Plan to pay for the dental service. You say that the service should be covered. The Plan denied
your request. The Plan says diagnostic casts 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 Evidence of Coverage clearly states that any services not listed are
not covered. Therefore, we decided that the Plan does not have to pay for the diagnostic casts (D0470)
provided on June 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on March 4, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on March 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveRituxumab injection for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthis drug is not being prescribed for a medically accepted indication.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved drug compendia there is no documentation to support that the Rituxumab is medically reasonable, necessary, safe, or effective for the enrollee's inflammatory polyneuropathy.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 injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approveRituxumab injection for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional accessories.
You asked the Plan to pre-approve additional accessories. You say that the additional accessories are medically
necessary. The Plan denied your request. The Plan says the additional accessories 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 additional accessories. Our reviewer
says that the additional accessories are not medically necessary. Our physician reviewer found the
documentation does not support that the enrollee requires a seat pouch, plastic side guards or impact guards, a
privacy flap, or neoprene impact guards as these items exceed his medical need. Furthermore, the spine align
mini fit it is part of the already approved E2613 back cushion and exceeds the enrollee's medical need. The
documentation indicates the enrollee's approved wheelchair has standard push handles. There is no evidence
that push handles are also necessary as they would exceed the enrollee's medical need and are not reasonable
and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed
body member.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional accessories have not been met. Therefore, we decided that the Plan
does not have to pre-approve additional accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 29, 2020, by an OON provider.
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary and were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.
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 April 29, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on June 1,
2020, by an out-of-network (OON) provider.
You asked the Plan to pay for subsequent nursing facility care. You say that your physician provided medically
necessary services in good faith. In consideration for the services rendered, your doctor is seeking
reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical services
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with
non-contracted providers require prior authorization before services being rendered.
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 subsequent nursing facility care (99309) provided
on June 1, 2020, by an out-of-network (OON) provider.
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 necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 there are no services at the LTACH that the enrollee requires that are not already
available and covered at the current setting. Therefore, this request for LTACH services will be considered not
medically necessary. Continued care at the current setting is appropriate until more appropriate long-term care
needs are more clear.
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 pre-approve lap sleeve gastrectomy.
You asked the Plan to pre-approve lap sleeve gastrectomy. You say that the requested lap sleeve gastrectomy is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet LCD criteria for the requested lap sleeve gastrectomy.
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 lap sleeve gastrectomy. Our reviewer says that the enrollee does not meet LCD criteria for the requested lap sleeve gastrectomy. Our physician reviewer found the enrollee is with morbid obesity, essential hypertension, atrial fibrillation, pacemaker, and osteoarthritis. The enrollee's medications are amlodipine, metoprolol, and aspirin. There is no documentation of a psychiatric or psychological disorder or that the enrollee is currently under the care of a psychologist/psychiatrist; he is not on psychotropic medications. The enrollee was advised to consult cardiology, psychiatry, and nutrition for clearance. The medical records in the case file do not contain documentation that the enrollee has failed to maintain a healthy weight despite adequate participation in a structured dietary program overseen by a physician, registered dietician, a board certified specialist in renal nutrition, or a fellow of the American Dietetic Association. The documentation does not include one of the required comorbid conditions: type II diabetes mellitus, resistant hypertension despite medical treatment with maximal doses of three antihypertensive medications, refractory hyperlipidemia, obesity-induced cardiomyopathy, clinically significant obstructive sleep apnea, obesity-related hypoventilation, pseudotumor cerebri, severe arthropathy of the spine and/or weight-bearing joints, or nonalcoholic fatty liver disease. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lap sleeve gastrectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve lap sleeve gastrectomy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periapical x-ray (D0220), the denture adjustment (D5650), and the extraction (D7140) provided on July 27, 2020.You asked the Plan to pay forthe dental services. You say that this was an emergency. You say that your tooth broke at the gum line. You say that had you known it was going to be so involved, you would have gone to the oral surgeon where you would have only been responsible for a copayment. You also say that you only have 2 teeth which hold your lower denture in place, so this was very important.The Plan denied your request. The Plan says there is a $15 copayment for x-rays that you receive. The Plan also says the denture adjustment and extraction are not covered services.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, there is a $15 copayment for x-rays. Additionally, the denture adjustment and extraction are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe periapical x-ray (D0220), the denture adjustment (D5650), and the extraction (D7140) provided on July 27, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

e decided that the Plan does not have to pay for the endodontic therapy of a molar tooth provided.

You asked the Plan to pay for the endodontic therapy. You say that you were not advised that this service was not approved.The Plan denied your request. The Plan says this service is not a covered 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. The contract clearly states that endodontic therapy is covered for anterior and premolar teeth only.Therefore, we decided that the Plan does not have to pay fort he endodontic therapy of a molar tooth provided
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care you received from August 25, 2020, to September 4, 2020.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you shouldn't have to pay a copayment since this stay was needed as the result of the surgeon's error. The Plan denied your request. The Plan says you were charged this copayment 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 $300 copayment per day for days 1-5 for inpatient hospital care. You have been asked to pay a $300 copayment per day for days 1-5 for the inpatient hospital care. This cost sharing applies regardless of the reason for your hospital stay. 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 inpatient hospital care you received from August 25, 2020, to September 4, 2020.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitationtherapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

e decided that the Plan does not have to waive the coinsurance forthe knee orthosis (L1833) provided June 30, 2020.You asked the Plan to waive the coinsurance forthe orthosis. You say that you received the brace from the doctor's office which is meant for people  who have surgery. You only wore it for 3 days and it didn't even help and now you're being billed over $130 for it.The Plan denied your request. The Plan says the claim was processed and the correct coinsurance was applied per the Evidence of Coverage.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% coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies. for Durable medical equipment (DME) and related supplies. You have been asked to pay $132.49 for the orthosis. The provider billed $785. The plan paid $530.00. 20% of the total amount which is $132.49. The orthosis falls within the Durable medical equipment (DME) and related 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 thecoinsurance forthe knee orthosis (L1833) provided June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvelumbar spine fusion.You asked the Planto pre-approvethe fusion. You say that this is medically necessary, as your pain level is intense.The Plandenied your request. The Plansaysthere is not enough information to show why the surgery is needed.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 therequest to pre-approve the fusion. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no clear documentation of spinal instability. More information would be needed to justify this surgery.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 fusion have not been met.Therefore, we decided that the Plandoes not haveto pre-approvelumbar spine fusion.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea wireless capsule endoscopy for the enrollee.You asked the Planto pre-approvethe endoscopy. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is 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 the endoscopy. Our reviewer says that the requested endoscopy is not considered medically reasonable and necessary in this case. Our physician reviewer found the available records fail to support the meeting of any of the possible indications for wireless capsule endoscopy. The record supports multiple contributors to anemia, and many sources of GI intermittent/recurrent GI blood loss have already been identified by EGD.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 endoscopy have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea wireless capsule endoscopy for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 13, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says on-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's 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 physician's services provided on February 13, 2020.