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

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on November 5, 2019.
You asked the Plan to waive the copayment for an emergency room visit. You say that the quality of care you received was horrible. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an emergency room visit. an emergency room visit falls within the emergency 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 waive the copayment for an emergency room visit provided on November 5, 2019.
Your quality of care concerns have been handled separately by the Plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electrical stimulation (97032), ultrasound therapy (97035), mechanical traction therapy (97012), and therapeutic exercises (97110).You asked the Plan to pre-approve electrical stimulation, ultrasound therapy, mechanical traction therapy, and therapeutic exercises. You say that the services are necessary.The Plan denied your request. The Plan says the requested services are not covered benefits.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pre-approve electrical stimulation (97032), ultrasound therapy (97035), mechanical traction therapy (97012), and therapeutic exercises (97110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).You asked the Plan to pre-approve the Prolia. You say that the Prolia is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says there is no record that the member has a history of osteoporotic fracture or failure or contraindication to zoledronic acid.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria.The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Prolia. Our reviewer says that there was no report by the treating physician or any other evidence found in the records showing that zoledronic would likely be significantly less effective than Prolia or be harmful or not tolerated. Current evidence comparing the two medications shows statistically similar patient satisfaction and very similar effectiveness. Our physician reviewer found the records do not show any history of osteoporotic fracture.
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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe definitive drug testing rendered to the enrollee on April 29, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says there is no valid physician order for code G0483.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is novalid physician order in the submitted documentation. 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 pay forthe definitive drug testing rendered to the enrollee on April 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power mobility device.You asked the Plan to pre-approvethe power mobility device. You say that you were not recommended a manual wheelchair because of neck problems, and you live on a steep hill and can't use a cane or walker.The Plan denied your request. The Plan says you do not meet the criteria for coverage of the device.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approvea power mobility device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545 for the enrollee.
You asked the Plan to pre-approve the compression stockings. You say that the enrollee requires Velcro compression wraps due to severe lymphedema. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means that the enrollee does not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea segmental pneumatic compression device.You asked the Plan to pre-approvethe requested device. You say that you have tried multiple other methods to control pressure and circulation, which did not work.The Plan denied your request. The Plan says you have not had a four week trial of a PCD as coded by E0650 or E0651.The Plan follows Medicare rules. Medicare rules say that a pneumatic compression device is covered only under certain medical indications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pre-approve the requested device. Our physician reviewer found you have bilateral lower extremity edema and pain from venous insufficiency. A clinical note dated January 6, 2020 describe a plan of compression stockings, elevation and frequent ambulation were recommended along with recommendation for tactile pump. The second note dated January 28, 2020, documented that your pain and swelling are worse with a basic pump (failed treatment), and now recommending a segmented pump. On review of the limited available medical records, you do not meet the coverage criteria for the requested device. You have lymphedema, but have not tried the previous pump for 4 weeks. There is no documentation that lymphedema was extending onto the chest, trunk and/or abdomen in the notes.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 requested device have not been met. Therefore, we decided that thePlan does not have to pre-approve a segmental pneumatic compression device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx testing rendered to the Enrollee on March 1, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that NGS 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee received FoundationOne CDx testing for a diagnosis of unspecified malignant melanoma of the skin. There is no documentation that the enrollee has recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and, either not been previously tested using the same NGS test for the same primary diagnosis of cancer, or repeat testing using the same NGS test only when a new primary cancer diagnosis is made by the treating physician; and, that the enrollee has decided to seek further cancer treatment. The testing was therefore 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 pay for the FoundationOne CDx testing rendered to the Enrollee on March 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe BRCA genetic testing rendered to E. McAmis on September 17, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan mustfollow Medicare rules. The rules say that to be eligible for Medicare coverage of BRCA testing, the individual being tested must have signs or symptoms of breast cancer, ovarian cancer, pancreatic cancer, or prostate cancer.We looked at the file and Medicare rules. The file does not show that the enrollee had a personal history of cancer for which BRCA testing is covered by Medicare.Therefore, we decided that the Plan does not have to pay forthe BRCA genetic testing rendered to E. McAmis on September 17, 2019. Local Coverage Determinations (LCDs) L35025 and L36082 referenced by the plan are for the incorrect jurisdiction and were not used in the MAXIMUS determination.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to the enrolleeby an out-of-network provider on September 23, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe services provided to the enrollee by an out-of-network provider on September 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the Enrollee on December 14, 2018.
You asked the Plan to pay for these 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 laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered to the Enrollee on December 14, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fora transvaginal ultrasound (76830) provided on July 8, 2019.You asked the Plan to pay fora transvaginal ultrasound. You say that this service was recommended due to the enrollee's family history.The Plan denied your request. The Plan says this is a non-covered screening test.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, a transvaginal ultrasound, was requested solely for screening purposes. It was billed with diagnosis Z12.73: encounter for screening for malignant neoplasm of ovary. Medicare does not cover this test solely for screening purposes.Therefore,we decided that the Plan does not have to pay fora transvaginal ultrasound (76830) provided on July 8, 2019
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (90834) provided on
August 7, 2019 to October 2, 2019
You asked the Plan to pay for the outpatient mental health services. You say that you have been seeing this
doctor for 11 years and services should be covered. The Plan denied your request. The Plan says there are innetwork
providers who can provide these services. No preauthorization was given and the services were not
emergent in nature.
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 outpatient mental health services (90834)
provided on August 7, 2019 to October 2, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transports provided on September 30, 2019.You asked the Plan to waive the copayment forthe ambulance transports. The Plan denied your request. The Plan says that you pay $275 for Medicare-covered ambulance services per day.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 $275 copayment for Medicare-covered ambulance services per day. You have been asked to pay a $275 copayment for the ambulance transports. The ambulance transports fall within the Medicare-covered ambulance services per day 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 forthe ambulance transports provided on September 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Cardiac Contractility Modulation System for the enrollee.You asked the Plan to pre-approvethe system. You say that this is medically necessary.The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem.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 thePlan was correct in denying the request to pre-approve the system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the OPTIMIZER Smart System which delivers CCMtherapy has been studied only in patients with ongoing heart failure while on optimal medical therapy who are in normal sinus rhythm, are not candidates for cardiac resynchronization therapy and have QRS duration less than 130m/sec. In addition, the OPTIMIZER system has been studied only in relatively small numbers of patients with no long term follow up beyond 1 year and not in patients who do not fit the above criteria such as the enrollee in appeal who has intermittent atrial fibrillation and QRS duration more than 130m/sec with biventricular cardiac resynchronization already in place. Therefore, CCM therapy should be considered investigational for the enrollee. 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 system have not been met.Therefore, we decided that the Plan does not have to pre-approvea Cardiac Contractility Modulation System for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on August 1, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that you never took an ambulance on this date of service.The Plan denied your request. The Plan says that the copayment applies to the emergency ambulance transport.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 Medicare-covered ambulance services per day. You have been asked to pay a $50 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered ambulance services 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 ambulance transport provided on August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (CPT 97530, CPT 97035) provided
to the enrollee on September 6, 2019.
You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary.
The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for the chiropractic services (CPT 97530, CPT 97035) provided to the
enrollee on September 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.You asked the Plan to pre-approve SNF care.You say that inpatient skilled nursing care is medically necessary.The Plan denied your request. The Plan says the patient does not meet criteria for coverage of a SNF admission.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 SNF care. Our reviewer says that the enrollee does not meet criteria for coverage of a skilled nursing facility care admission. Our physician reviewer found the records do not support that the enrollee needs skilled nursing or skilled therapy on a daily basis. She is ambulating household distances and requires little assistance with mobility and transfers. While the enrollee may benefit from continuing physical and occupational therapy, she does not require the necessary services on 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis provided from September 21, 2019 to September 28, 2019.
You asked the Plan to waive the coinsurance for dialysis. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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% coinsurance for renal dialysis. You received dialysis from September 21, 2019 to September 28, 2019. The total allowed amount is $1,300 and 20% of that is $260. You have been asked to pay the total coinsurance amount of $260 for dialysis. Dialysis falls within the services to treat kidney disease 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 dialysis provided by from September 21, 2019 to September 28, 2019.