Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the limited oral evaluation (D0140), the
bitewing x-ray (D0270), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and 3
extractions (D7140) provided from February 1, 2021, to February 10, 2021.
You asked the Plan to pay the full amount for the dental services. You say that you think that this bill is too
high. You say that you understand that the Plan pays the full amount. You also say that this insurance paid very
little. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also
says that for services performed out of network, you might be billed for any amount greater than what the plan
pays.
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 and the services are listed as covered,
out of network providers may bill you for any amount greater than what the plan pays.
TOTAL: $435
Therefore, we decided that the Plan does not have to pay the full amount for the limited oral evaluation
(D0140), the bitewing x-ray (D0270), the initial periapical x-ray (D0220), the additional periapical x-ray
(D0230), and 3 extractions (D7140) provided from February 1, 2021, to February 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided on June 5, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you met the MOOP amount prior to receiving the services so you should not be responsible for 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 the MOOP amount for 2020 is $4,500. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.
You received a Medicare Part B drug on June 5, 2020. The record shows that you had only paid $3,669.61 toward the $4,500 MOOP amount prior to receiving the services. Therefore, you are responsible to pay the remaining MOOP balance of $830.39, which is less than the 20% coinsurance amount. You have been asked to pay the $830.39 for a Medicare Part B drug injection. A Medicare Part B drug 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 a Medicare Part B drug injection provided on June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and occlusal guard provided on March 1, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and occlusal guard. You say that the Plan's website showed this treating provider was in-network with your plan. The Plan denied your request. The Plan says these 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 problem focused limited oral evaluation, first intraoral periapical x-ray, and occlusal guard provided on March 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP device (E0601).
You asked the Plan to pre-approve a CPAP. You say that the prior trial of CPAP was failed to lack of guidance
as to proper operation. The Plan denied your request. The Plan says rules for a CPAP have not been met
because the requested item is 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 a CPAP. Our reviewer says that the
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found
that the record indicates that the enrollee had a sleep study in March 2020 and a CPAP prescription and doctor
visit in August 2020. A new prescription was written in April 2021. The record does not indicate that a reevaluation
or a repeat sleep study has been performed. The elements of the coverage criteria are not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a CPAP have not been met. Therefore, we decided that the Plan does not have
to pre-approve a CPAP device (E0601).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on March 19, 2021.
You asked the Plan to pay for the office visit, application of modality, and therapeutic procedure. You say that you want to know why you were denied the medical services, you have back spasms and pain. The Plan denied your request. The Plan says any other service besides manual manipulation of the spine to correct a subluxation performed by a chiropractor are not covered.
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 provided on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 17, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the service was medically necessary, and the enrollee was in a nursing facility and had no control over which physician would be assigned to their case. The Plan denied your request. The Plan says no prior authorization was obtained.
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 item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on March 17, 2021 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0482) provided on October 15, 2020.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with the correct POS code.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. Although these services were billed with POS 81 for an independent laboratory, the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (80307, G0482) provided on October 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from December 26, 2020, to December 28, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you would like to appeal these drugs. The Plan denied your request. The Plan says the self-administered drugs are not Part B covered.
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 pay for the self-administered drugs provided from December 26, 2020, to December 28, 2020.
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the blood draw using established catheter
provided on December 17, 2020.
You asked the Plan to waive the copayment for the blood draw using established catheter. You say that you
were not in an operating room and there was no surgical procedure. 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 $180
copayment for surgery services at an in-network outpatient hospital. For this date of service, you have been
asked to pay the allowed amount of the claim because this amount is less than the standard $180 copayment for
the blood draw using established catheter.
You have been asked to pay a $109.62 copayment for the blood draw using established catheter. The blood draw using established catheter falls within the "Outpatient hospital services" benefit category. The record shows you were billed for code 36592 which is considered a surgical procedure.
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 blood draw using established catheter provided on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections (J0585) to be rendered by the out of network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says an in-network provider is available to render the requested 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve Botox injections (J0585) to be rendered by the out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on March 24,
2021.
You asked the Plan to waive the copayment for the laboratory work. You say that the laboratory services
should have been covered with your annual physical exam. You say the laboratory work was not done at the
hospital. 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 $50
copayment for laboratory services at an in-network outpatient hospital. For this date of service, you have been
asked to pay the allowed amount of the claim because this amount is less than the standard $50 copayment for
the laboratory work.
You have been asked to pay a $38.52 copayment for the laboratory work. The laboratory work falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the
laboratory work is not considered a part of the annual physical and you were billed by the outpatient hospital.
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 laboratory work provided on March 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Avastin, Folfoxiri and Capecitabine in combination for the enrollee.
You asked the Plan to pre-approve Avastin, Folfoxiri and Capecitabine. You say that the use of this drug combination 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 Avastin (Bevicizumab), to be used with Capecitabine and Folfoxiri). The Maximus Physician Reviewer determined that Avastin was medically necessary in this case. The Plan requested a reopen and states that they have been unable to identify the specific NCCN guidance for the use of Avastin, Folfoxiri and Capecitabine for the clinical situation documented in this case. The medical records show the enrollee is a 71-year-old man with recurrent colorectal adenocarcinoma. The requested regimen was Avastin (Bevacizumab), with Folfoxiri (5-fluorouracil, oxaliplatin, and irinotecan), and Capcetabine as palliative treatment.
Our Medical Director has concluded that the Plan is correct in this case. There is insufficient support in the medical literature regarding the use of Avastin (Bevicizumab), Capecitabine and Folfoxiri for the treatment of recurrent colorectal cancer. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Avastin, FOLFOXIRI and Capecitabine have not been met. Therefore, we decided that the Plan does not have to pre-approve Avastin, Folfoxiri and Capecitabine in combination for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee brace.
You asked the Plan to pre-approve a knee brace. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested item is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a knee orthosis is only covered when the enrollee has
had a recent injury to or a surgical procedure on the knee(s).
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 a knee brace. Our reviewer says that the
documentation does not support that the requested knee brace is medically reasonable or necessary. Our
physician reviewer found the enrollee has knee pain unrelated to surgery or injury. The record does not
indicate that there is knee instability. Therefore, the enrollee does not meet criteria for the requested brace.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a knee brace have not been met. Therefore, we decided that the Plan does not
have to pre-approve a knee brace.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing (87486, 87581, 87798) provided on July 8, 2020.
You asked the Plan to pay for laboratory testing. You say that this service could not be performed at the place the specimen was collected. The Plan denied your request. The Plan says this service must be billed with the POS code for the place the specimen was collected.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. Although the service was performed in the independent laboratory as represented by the billed POS code 81, Medicare rules require laboratory service to be billed with the POS code representing the location in which the sample was taken. Based on this information, we decided that Medicare rules for coverage of laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing (87486, 87581, 87798) provided on July 8, 2020.
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 you need LTACH care. The Plan denied your request. The Plan says rules for LTACH care have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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: 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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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 does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care.
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. Specifically, there is no medically necessary service that the LTACH offers that the enrollee is not already receiving at their current level of care. This means admission into a LTACH is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
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 need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 that you have a past medical history of ankle arthrodesis on September 29, 2020. He was admitted to inpatient rehabilitation from January 30, 2021, to February 22, 2021, and have been discharged
home since. You remain non weightbearing. Medical conditions 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. Although you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, 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 inpatient rehabilitation facility (IRF) admission and services.