Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.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 the enrollee appears to be improving and more stable but requires only short-term additional acute care services which can be safely administered at the current acute care setting. There are no services at the LTACH that are not already available and covered at the current setting. Transfer may be considered when treatment has been completed.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-approvelong term acute care hospital (LTACH) services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFosamax tablets.You asked the Plan to pre-approveself-administered drug. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveFosamax tablets.Benefits for self-administered drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitoring (CGM) system.You asked the Plan to pre-approvecontinuous glucose monitor. You say that the Plan did not have up to date information regarding this request.The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the documentation does not support that you take frequent insulin shots, blood glucose checks,or insulin dosing adjustments based on blood glucose.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at leastfour times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitoring (CGM) system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the extraction (D7140) and the periodic oral evaluation (D0120) provided on August 3, 2020.
You asked the Plan to reimburse you for the dental services. You say that you called prior to your appointment to obtain clarification on your coverage. You say that you were told you would not be limited to network providers and could go to a doctor of your choice. You also say that there was no mention of opt out providers. The Plan denied your request. The Plan says the dentist in this case has opted out of Medicare. The Plan also says that payment cannot be made to dentists who have opted out of Medicare.
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 reimburse you for the extraction (D7140) and the periodic oral evaluation (D0120) provided on August 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Part B drugs provided from October 27, 2020, to November 3, 2020.You asked the Plan to waive the coinsurance forthe Part B drugs. You say that you may have changed your mind to have the treatments if you had known the cost. The Plan denied yourrequest. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% for Medicare-covered Part B medication, including, but not limited to, chemotherapy and drugs used during outpatient diagnostic procedures. You have been asked to pay 20% of the allowed amount for the Part B drugs on each date of service. The allowed amount is $394.75. ($394.75 x 20% = $78.95). ($78.95 x 2 = $159.70). The Part B drugs fall 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 forthe Part B drugs provided from October 27, 2020, to November 3, 2020.Your complaint about the Plan representations giving inaccurate information is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you are in a lot of pain and cannot walk with your right foot. You say that this affects you mentally and emotionally. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and 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 pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinsertion of an interspinous spacer device (Vertiflex).You asked the Plan to pre-approveVertiflex. You say that Medicare has determined that these are covered services.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is experimental/investigational.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/investigational because of the number of re-operations and how this procedure fits into established evidence-based algorithms of care of spinal stenosis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of an interspinous spacer device (Vertiflex).
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 enrollee would benefit and improve with LTACH, with an expected length of stay of greater than 25 days. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 the enrollee requires additional acute care services which can be safely administered at the current acute care setting. The enrollee does not require services at the LATCH that are not already available and covered at the current setting. Transfer may be considered when treatment has been completed. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forinpatient services provided to the enrollee on March 28, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows thata claim for the services was not filed until August 27, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plandoes not haveto pay forinpatient services provided to the enrollee on March 28, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided on August 6, 2020, and September 10, 2020.You asked the Plan to pay forthe dental services. You say that you received approval for these services from the Plan, and they should be paid.The Plan denied your request. The Plan says the provider failed to provide diagnosis codes when billing these claims. Without correct diagnosis codes, the claims cannot be paid.The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient information to the Plan to determine whether payment is due.We looked at the file and Medicare rules. Claims must be filed with diagnosis codes which indicate the need for the rendered services. A claim with no diagnosis codes is not correctly completed. Based on this information, we decided that Medicare rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pay forthe dental services provided on August 6, 2020, and September 10, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan does not have to pay forinpatient rehabilitation (IRF) services provided to the enrollee from October 23, 2019 to October 31, 2019 and billed under the above-mentioned claim number. You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information provided regarding the claim issue. The Plan requested a reopen and provided additional information regarding thebilling denial. The Plan states this claim denied because this service was billed inappropriately. The Plan states as an IRF, the provider should have billed with both the revenue code and the HIPPS ratecode to identify the CMGpayment classification forthe beneficiary.The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the claim submitted cannotbe paid as billed due to the omission of the codes required by Medicare as stated above in the Medicare rules. Therefore, we decided that the Plan does not have to pay forinpatient rehabilitation (IRF) services provided to the enrollee from October 23,2019 to October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services with dental code D0180 provided on September 28, 2020.You asked the Plan to pay fordental code D0180. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the service is not covered under the 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, dental code D0180 is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe dental services with dental code D0180 provided on September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvecommode chair and walker. You say that you are appealing the Plan's denial.The Plan denied your request. The Plan says the denial of authorization for these items is correct, because this provider is out-of-network with the Plan and these items can be obtained from an in-network supplier.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-approvethe medical services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental extraction from an oral surgeon.
You asked the Plan to pre-approve the dental extraction from an oral surgeon. You say that you are in a lot of pain and need an extraction. You say that you have been waiting to be seen by an oral surgeon for over a month. The Plan denied your request. The Plan says the services being requested are 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 services covered under this benefit are limited to services performed by a participating general dentist. The dentist you are requesting the dental extractions from is an oral surgeon. Therefore, we decided that the Plan does not have to pre-approve a dental extraction from an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral X-ray
(D0220), each additional intraoral X-ray (D0230) and dental cleaning services (D1110) provided on September
9, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the periodic oral evaluation, first intraoral X-ray, each additional intraoral X-ray,
and dental cleaning services. You say that you would like this claim reprocessed and approved for payment.
The Plan denied your request. The Plan says they only pay for dental services when rendered by an in-network
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. The Plan covers the periodic
oral evaluation, first intraoral X-ray, each additional intraoral X-ray, and dental cleaning services when the
services are rendered by an in-network provider.
We looked at this physician's review, the file, and Medicare rules. 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 Therefore, we decided that the Plan does not have to pay for the periodic
oral evaluation (D0120), first intraoral X-ray (D0220), each additional intraoral X-ray (D0230) and dental
cleaning services (D1110) provided on September 9, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 24 routine transportation trips.
You asked the Plan to pre-approve routine transportation. You say that you are currently receiving treatment at this location and cannot stop treatment. The Plan denied your request. The Plan says the denial of authorization for routine transportation to this location is correct, because this destination is not within 35 miles and is outside of the Plan's service area.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation to Plan-approved locations within the Plan's service area and within 35 miles. We looked at your request, the records in the case file, and the rules. The requested destination is not within the Plan's service area. Additionally, trips to this destination would be over 35 miles and the Plan has not granted authorization. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 24 routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the injection provided on October 19, 2020.

You asked the Plan to waive the cost share for the services provided. You say that it would be a hardship to pay the amount. The Plan denied your request. The Plan says the claim processed 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% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay a 20% coinsurance for the services provided. The services fall 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 cost share for the injection provided on October 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial images (D0350 x 4), the panoramic x-ray (D0330), and the complete series x-ray (D0210) provided on September 16, 2020.

You asked the Plan to pay for the dental services. You say that you requested a cleaning and x-ray package that your plan offered. You say that the 2D oral/facial images was a service not covered and therefore should not have been done without you being notified there would be an extra charge. You also say that you were left alone in a chair for many hours before calling out numerous times for help. The Plan denied your request. The Plan says the 2D oral/facial images are not listed as covered service. The Plan says that the complete series x-ray and panoramic x-ray share a frequency limit of 1 procedure every 5 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, 2D oral/facial images are not among those covered under this benefit. Additionally, the frequency limit of 1 complete series x-ray or 1 panoramic x-ray has been exceeded. The record shows that the Plan paid for the complete series x-ray that you received on this date of service. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial images (D0350 x 4), the panoramic x-ray (D0330), and the complete series x-ray (D0210) provided on September 16, 2020.

Your complaint about your experience at your appointment is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive to cost shares for the continuous positive airway pressure (CPAP) device provided from August 2, 2020, to October 2, 2020.
You asked the Plan to waive to cost shares for the CPAP device. You say that you paid off your CPAP machine. The Plan denied your request. The Plan says the claim processed 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% coinsurance for durable medical equipment. You have been asked to pay a 20% coinsurance for each month for the CPAP device. The CPAP device falls within the durable medical equipment 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 to cost shares for the continuous positive airway pressure (CPAP) device provided from August 2, 2020, to October 2, 2020.