Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zoomer Chair.
You asked the Plan to pre-approve the Zoomer Chair. You say that you cannot walk. The Plan denied your
request. The Plan says the Zoomer Chair does not fit under the category of DME and therefore would not be
eligible for coverage.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The website for the Zoomer Chair (www.zoomerchair.com) states: "The Zoomer Chair is a personal electric
vehicle and is not a medical device nor a wheelchair, and has not been submitted to the Food and Drug
Administration for review or clearance. Zoomer is not intended for medical purposes to provide mobility to
persons restricted to a sitting position. It is not covered by Medicare or Medicaid." This is not covered by
Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve Zoomer Chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2025), anti-reflective coating, per lens (V2750TG), tint photochromatic lens/es (V2744) and lens, polycarbonate or equal, any index, per lens (V2784) provided on January 30, 2020.
You asked the Plan to pay for the eyewear. You say that it is your understanding that your policy covers one (1) pair of eyeglasses after cataract surgery with a $50 copay. The Plan denied your request. The Plan says the items are not covered under Medicare or the Health Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Your contract only provides coverage for standard glasses or contacts after cataract surgery.
Therefore, we decided that the Plan does not have to pay for deluxe frames (V2025), anti-reflective coating, per lens (V2750TG), tint photochromatic lens/es (V2744) and lens, polycarbonate or equal, any index, per lens (V2784) provided on January 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Arikayce 590 mg/8.4 ml vial.
You asked the Plan to pre-approve Arikayce. You say that this medication is medically necessary. The Plan
denied your request. The Plan says coverage for this drug is not available under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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-approve Arikayce 590 mg/8.4 ml
vial.
Benefits for Arikayce may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the insulin injections (J1815) provided from January 25,
2020 to January 28, 2020.
You asked the Plan to pay for the insulin injections. You say that these injections were given to you in an
emergency situation. You also say that your blood count was over 500. The Plan denied your request. The Plan
says this drug is self-administered and is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pay for the insulin injections (J1815)
provided from January 25, 2020 to January 28, 2020.
Benefits for the insulin injections may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to
the enrollee on November 20, 2019.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic
profiling for NSCLC, and the appropriate DEX Z-Code identifier must be entered adjacent to the CPT code
[81479] in the comment/narrative field.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on November 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for acute inpatient rehabilitation care from
December 30, 2019 through January 15, 2020.
You asked the Plan to waive the copayment for acute inpatient rehabilitation care. You say that you are
appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan
says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received acute inpatient rehabilitation care from December 30, 2019 through
January 15, 2020. Your EOC states, "enrollees must pay a $500 copayment per admission for inpatient hospital
care. Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient
hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor's
order. The day before you are discharged is your last inpatient day." Therefore, you are asked to pay a $500
copayment per admission for the services. 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 acute
inpatient rehabilitation care from December 30, 2019 through January 15, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to reimburse the copayment for inpatient hospital services provided on February 19, 2020.
You asked the Plan to reimburse the copayment for inpatient hospital services. You say that you were told that if you were released the same day you would only owe a $50 copayment and be reimbursed the difference. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.
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. The Plan did not provide medical records. Without medical records we cannot determine whether inpatient hospital services were provided or not. Therefore, we decided that the Plan has to reimburse the copayment for inpatient hospital services provided on February 19, 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: 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 you are appealing for IPR due to safety concerns at home secondary to impaired cognition. The Plan denied your request. The Plan says the enrollee does not meet the medical necessity criteria. Services can be safely provided at a lower level of care such as SNF with skilled therapy or home with HHC therapy and family assistance.
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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the enrollee's functional status requires an 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased March 16, 2020 from an out-of-network provider.
You asked the Plan to pay for the hearing aids. You say that the hearing aids you bought were not offered by either network provider, were 1/3 of the price of anything offered by either company and were much smaller and less noticeable to wear. The Plan denied your request. The Plan says hearing services must be rendered by the Plan's designated in-network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from the Plan's designated in-network vendor. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased March 16, 2020 from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom foot inserts, for the enrollee.
You asked the Plan to pre-approve foot orthotics. You say that the durable medical equipment is medically
necessary. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace.
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve custom
foot inserts, for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the services you received on March 10,
2020.
You asked the Plan to waive the cost share. You say that you were not told about the charges. The Plan denied
your request. The Plan says you are responsible for the cost share.
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. Your contract also says that you must pay a $20
copayment for each specialist visit.
Review of the file shows that you had a specialist visit and were provided Part B drugs on March 10, 2020.
You have been asked to pay a 20% coinsurance for the drugs and a $20 copayment for the 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 cost share for the services you received on March 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for tint, photochromatic lenses (V2744) and bifocal lenses (V2200) purchased August 6, 2019.
You asked the Plan to pay for the vision services. You say that you are requesting reconsideration because you called the plan and was told how much you could spend and you paid the rest. The Plan denied your request. The Plan says the benefit has been exhausted.
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 any amount above the $200 eyewear benefit. You have been asked to pay $126.36 for the vision services. The vision services fall within the Vision care 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 pay for tint, photochromatic lenses (V2744) and bifocal lenses (V2200) purchased August 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that the enrollee is making progress but is
nowhere near where he was prior to admission to the hospital and in no condition to stop care and therapy and
go home. The Plan denied your request. The Plan says the enrollee no longer qualifies for care at the SNF level.
Services can be safely provided in another setting such as home with home health, in residential care or home
with close doctor follow up.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled
nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a
daily basis and 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 SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient practitioner visit provided on February 26, 2020.
You asked the Plan to pay for the inpatient visit. You say that you feel that this should be covered. The Plan denied your request. The Plan says that the billing provider is a registered nurse and cannot be paid by Medicare for this 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. The Plan indicates that this claim was denied since the provider's taxonomy code (code for type of provider) is registered nurse, which is not payable by Medicare. The Plan is incorrect in this statement. Maximus verified that this provider's primary taxonomy code is nurse practitioner which is a Medicare allowed type of provider. The Plan did not provide any other cogent denial rationale. As such, we find that the denial of payment for this visit is not valid. Therefore, we decided that the Plan has to pay for the inpatient practitioner visit provided on February 26, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extraction, erupted tooth or exposed root (elevation and/or
forceps removal) (D7140), removal of impacted tooth - partially bony (D7230) and removal of residual tooth
roots (cutting procedure) (D7250) provided from October 28, 2019 through January 21, 2020 by an in-network
provider.
You asked the Plan to pay for the dental services. You say that you were under the impression that the policy
would cover your extractions. The Plan denied your request. The Plan says surgery performed primarily to
prepare the mouth for dentures is a noncovered procedure.
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 services are not listed in your EOC as a covered benefit; therefore,
the services are not covered and surgery performed primarily to prepare the mouth for dentures is a noncovered
procedure. Therefore, we decided that the Plan does not have to pay for extraction, erupted tooth or exposed
root (elevation and/or forceps removal) (D7140), removal of impacted tooth - partially bony (D7230) and
removal of residual tooth roots (cutting procedure) (D7250) provided from October 28, 2019 through January
21, 2020 by an in-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on
August 21, 2019.
You asked the Plan to pay for the presumptive and definitive testing. You say that this should be covered. The
Plan denied your request. The Plan says there was no valid order for this testing.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a
treating provider.
The file does not include a copy of any order form for this testing. Therefore, we decided that the Plan does not
have to pay for the presumptive and definitive drug testing provided on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 20, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
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 March 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft provided on April 16, 2020.
You asked the Plan to pay for the bone replacement graft. You say that you aren't getting this done for cosmetic
reasons. You say that this needs to be done to preserve your chewing ability and healthy teeth. The Plan denied
your request. The Plan says the 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. Therefore, we decided that the Plan does not have to pay for the bone
replacement graft provided on April 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive exam (for a new patient, or an established
patient after 3 or more years of inactivity from dental treatment) (D0150) provided on March 5, 2020.
You asked the Plan to pay for the dental services. You say that you did not know that there was a limit on the
exam. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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.
You exhausted your benefit frequency limit, because you had this same service done on March 4, 2019. Your
EOC states, comprehensive exam (for a new patient, or an established patient after 3 or more years of inactivity
from dental treatment) (D0150) - one (1) procedure every three (3) plan years. Therefore, we decided that the
Plan does not have to pay for comprehensive exam (for a new patient, or an established patient after 3 or more
years of inactivity from dental treatment) (D0150) provided on March 5, 2020.