Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 

The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

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 proton beam therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than intensity-modulated radiation therapy/image-guided radiation therapy (IMRT/IGRT). The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. For this enrollee, there are no clinical records ore plausible rationale for why proton therapy would be 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 proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the foot x-ray (73630) provided on September 23, 2020.
You asked the Plan to pay for the foot x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that 73630's global component has already been billed and paid to another provider for the same date of service.
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 forwarded evidence that this service has been previously billed and paid. There is insufficient evidence provided by the Plan to substantiate their denial. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for the foot x-ray (73630) provided on September 23, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physician services provided on July 10,
2020.
You asked the Plan to waive the copayment for the physician services. You say that you are being charged for a
telephone consult and office visit that did not occur. You say that the cost should be reduced. The Plan denied
your request. The Plan says the claims reprocessed to only apply one $50 copayment.
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 $50
copayment for each Medicare-covered specialist visit.
You have been asked to pay a $50 copayment for the physician services. The physician services fall within the
"Physician/Practitioner services, including doctor's office visits" 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 the physician services provided on July 10, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on February 4, 2020.
You asked the Plan to waive the copayment for the endoscopy. You say that the copayment is too high. 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 $250 copayment for surgery services at an in-network ambulatory surgical center. You have been asked to pay a $250 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 the endoscopy provided on February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L2397, L1833) provided September 5, 2020.
You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes L2397, & L1833 are not supported in the medical record. Specifically, the plan's records show the patient did not receive a video or telephonic visit by the ordering physician. Additionally, there is no record of the enrollee ever receiving services from the ordering physician previously. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for orthoses (L2397, L1833) provided September 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Limited oral evaluation - problem focused (D0140) and Panoramic Radiographic images (D0330) provided October 20, 2020.
You asked the Plan to pay for the problem focused oral evaluation and panoramic x-rays. You say that the services were medically necessary. The Plan denied your request. The Plan says the 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 pay for the Limited oral evaluation - problem focused (D0140) and Panoramic Radiographic images (D0330) provided October 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty multiple braking system and seat attachment for a walker.
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. The rules say that a heavy duty multiple braking system is covered when specific criteria are met. 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 chronic pain syndrome and chronic low back pain. You have normal strength and no evidence of instability. The criteria for coverage of the heavy duty multiple braking system are not met. The requested braking system and seat attachment are not reasonable and medically necessary for your condition. 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 heavy duty multiple braking system and seat attachment for a walker.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-network provider.
You asked the Plan to pre-approve chiropractic services. You say that you have severe pain if you don't get these adjustments. The Plan denied your request. The Plan says after your remaining visits left covered under your supplemental benefit, care must be received 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous image-guided lumbar decompression (PILD) surgery.
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 magnetic resonance imaging (MRI) report does not show that you have severe lumbar spinal stenosis. You are not enrolled in a Medicare-approved clinical trial or CED study; therefore, the criteria for coverage are not met. The services are 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 percutaneous image-guided lumbar decompression (PILD) surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and prophylaxis provided on January 8, 2020 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and prophylaxis. You say that you were not advised that this provider was OON at the location you received these services. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that you are responsible for 100% of the total amount for services from an OON provider.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and prophylaxis provided on January 8, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for gait disturbance, slurred speech, and atrial fibrillation. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy 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-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard-hard appliance, partial arch (D9946)
provided on October 27, 2020.
You asked the Plan to pay for the dental item. You say that the denial letter says there is a limit for occlusal
guards. You say that you would like a review of the denied claim for $984 because that means the benefit
covers the device. You also say that you have never had the service before. The Plan denied your request. The
Plan says occlusal guard-hard appliance, partial arch, is not listed as a covered service. The Plan says that you
called to verify dental benefits on October 20, 2020. The Plan also says that you were informed that the
mouthpiece is 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 pay for the
occlusal guard-hard appliance, partial arch (D9946) provided on October 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq (Atezolizumab).
You asked the Plan to pre-approve Tecentriq (Atezolizumab). You say that this drug is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Tecentriq (Atezolizumab). The Maximus Physician Reviewer determined the requested drug could be used in treatment for this condition. The Plan argues that there is insufficient evidence in the literature of the safety and efficacy of Tecentriq used along with carboplatin and etoposide as off-label use in your condition. Our Medical Director has concluded that the Plan is correct in this case. There is not sufficient evidence in the medical literature to support the use of Tecentriq (Atezolizumab) in the treatment of endometrial neuroendocrine carcinoma. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tecentriq (Atezolizumab) have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq (Atezolizumab).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 9, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you were in observation and should not have a copayment. 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 $30 copayment per visit for an in-network specialist. Covered services include medically necessary medical care or surgery services furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location. You have been asked to pay a $30 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 the office visit provided on October 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve the power scooter.. You say that the scooter is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The record shows the power scooter is primarily intended for community use. Documentation from a home evaluation does not clearly show that the scooter can safely be maneuvered inside the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the radiation therapy provided from May 14, 2020, to July 1, 2020.
You asked the Plan to waive the copayments for the radiation therapy. You say that you cannot afford this amount. 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 $60 copayment for each Medicare-covered radiation therapy service. You have been asked to pay a $60 copayment for 21 of the 22 radiation therapy visits. ($60 x 21 dates of service = $1,260). You have been asked to pay a $46.51 on the June 3, 2020 date of service because you met your maximum out-of-pocket amount. ($1,260 + $46.51 = $1,306.51). The radiation therapy 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 copayments for the radiation therapy provided from May 14, 2020, to July 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on
September 4, 2020.
You asked the Plan to waive the coinsurance for the denosumab injection. You say that you are on a fixed
income and you shouldn't be responsible for the drug administered. 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 cost for Medicare Part B chemotherapy drugs and other Medicare Part B drugs.
You have been asked to pay $693.16, which is less than the standard 20% coinsurance for the denosumab
injection. The denosumab injection falls within the "Medicare Part B prescription drugs" 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 coinsurance for the denosumab injection provided on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot insert or adjust the cost share for the ankle orthosis,
walking boot or podiatry services provided from May 22, 2020, to June 22, 2020.
You asked the Plan to pay for the foot insert and adjust the cost share for the ankle orthosis, walking boot and
podiatry services. You say that each claim should only have a $25 specialist copayment. The Plan denied your
request. The Plan says you were charged the cost share correctly and the foot insert was billed incorrectly.
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 $25
copayment for specialist services, 4% coinsurance for durable medical equipment, and you have a $500
deductible.
You have been asked to pay a $25 copayment for each visit, 4% coinsurance for the orthoses, and first meet the
$500 deductible. 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.
Records show that you do not wear a leg brace.
Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics
for your condition. Therefore, we decided that the Plan does not have to pay for the foot inserts or adjust the
cost share for the ankle orthosis, walking boot and podiatry services provided from May 22, 2020, to June 22,
2020.