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

We decided that the Plan does not have to pre-approve a power operated vehicle (POV).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan 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. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found the records show that you have a personal mobility deficit but the documentation does not support that it impairs your ability to participate in mobility-related activities of daily living (MRADLs) in the home, or that the mobility deficit cannot be helped by the use of a walker or manual wheelchair. While you may be able to safely operate the POV in your home, the records do not support that the POV is reasonable and medically necessary at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (POV).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a Cologuard test provided on February 3,
2021.
You asked the Plan to waive the deductible for a Cologuard test. You say that you should not owe anything for
a colorectal cancer screening. 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. Your
contract with the Plan says that there is a $5,600 yearly deductible. Your contract with the Plan also clearly
says that until the yearly deductible has been met, enrollee's pay 100% of the Medicare approved amount for
colorectal cancer screenings.
You received a Cologuard test on February 3, 2021. The record shows that you had only paid $138.30 toward
the $5,600 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount
of $508.87.
The item or service you asked the Plan to waive the deductible for falls within the benefit category colorectal
cancer screenings. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a
$5,600 yearly deductible for colorectal cancer screenings. This cost sharing is a contractual obligation that had
not been met at the time a Cologuard test was received on February 3, 2021. Therefore, we decided that the
Plan does not have to waive the deductible for a Cologuard test provided on February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, panoramic x-ray, and preventive procedure provided on November 18, 2020.
You asked the Plan to pay for the comprehensive oral evaluation, intraoral periapical x-rays, panoramic x-ray, and preventive procedure. You say that these services were necessary because you were a new patient. The Plan denied your request. The Plan says your benefits for the comprehensive oral evaluation, intraoral periapical x-rays, and panoramic x-ray have been satisfied and the frequency limitations have been exceeded. The Plan also says that the preventive procedure is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, unspecified preventive procedure is not among those covered under this benefit. The Plan contract says that comprehensive oral evaluation is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation on December 6, 2018 and your comprehensive oral evaluation benefit has been exhausted. The contract says that intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on February 12, 2020, and your intraoral x-rays benefit had been exhausted. The Plan contract also says that full mouth or panoramic x-rays are limited to one procedure every five years. The record shows that you received a complete series of intraoral x-rays on December 6, 2018 and your full mouth or
panoramic x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, panoramic x-ray, and preventive procedure provided on November 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care coded 99292 provided on June 22, 2020.
You asked the Plan to pay for the critical care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). We find that CPT code 99292 is not supported in the medical record. Specifically, this code represents an additional 30 minutes of critical care time in addition to the first 30-74 minutes of a critical care evaluation and management service CPT code 99291. The submitted medical records document 100 minutes of critical care time. They do not support that an additional 60 minutes of critical care services was performed in addition to the first 30-74 minutes of a critical care evaluation and management service CPT code 99291 to support the units billed with CPT code 99292. Based on this information, we decided that Medicare rules for coverage of the critical care have not been met. Therefore, we decided that the Plan does not have to pay for the critical care coded 99292 provided on June 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy evaluation services coded 97161 and the therapeutic activities coded 97530 provided on August 19, 2019.

You asked the Plan to pay for the physical therapy evaluation services and the therapeutic activities. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes 97161 and 97530 are not supported in the medical record. Specifically, medical records indicate that services were performed by a certified physical therapist assistant in the home health or hospice setting. This means there is a more appropriate code to be billed instead of 97161. Also, the submitted documentation does not indicate that a total of 15 minutes was spent providing the therapeutic activities for this date of service. Based on this information, we decided that Medicare rules for coverage of the physical therapy evaluation services and the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy evaluation services coded 97161 and the therapeutic activities coded 97530 provided on August 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from February 12, 2020, to February 16, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you needed these drugs for your pain. You say that you were in the emergency room. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
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 self-administered drugs provided in an outpatient setting from February 12, 2020, to February 16, 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: 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 intensive therapy just to manage daily living. The Plan denied your request. The Plan says your care could be better provided in a Skilled Nursing Facility.
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 there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage to the requested equipment.
You asked the Plan to pay for this equipment for the enrollee. You say that this device and supplies are medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial stating the device and supplies would be beneficial for the enrollee. The Plan requested a reopen and stated that whether or not the equipment would be beneficial is not the issue, the enrollee must meet all of the required criteria for approval and the medical records do not show that all of the required criteria are met.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs covered when all of the criteria listed in the Medicare coverage criteria are met. Based on the medical records provided, the enrollee does not meet all of the criteria required by Medicare for coverage of this device and supplies. While the use of the equipment may be beneficial for the enrollee, the medical record documentation but specifically demonstrate all required criteria are met. Therefore, we decided that the Plan does not have to provide coverage for a Freestyle Libre continuous glucose monitor for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a psychotherapy visit provided on January 19, 2021.
You asked the Plan to waive the copayment for psychotherapy visit. You say that there should be no copayment as this service was COVID-19 related. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $75 copayment for outpatient mental health services provided by an outpatient hospital. You have been asked to pay $75 copayment for psychotherapy visit. Psychotherapy visit falls within the Outpatient Mental Health 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 a psychotherapy visit provided on January 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided the Plan does not have to pay for skilled nursing facility services provided September 29, 2020.
You asked the Plan to pay for skilled nursing facility services provided September 28, 2020 and September 29, 2020. You say that these services should be paid by the Plan. The Plan paid September 28, 2020 and denied September 29, 2020. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that the approval of September 28, 2020 was in error because the Plan had already made payment for that date of service.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a skilled nursing facility when the four factors listed in the Medicare rules section are met. Custodial care is not covered. The room and board services provided on September 29, 2020 were custodial in nature and are not covered by Medicare. Therefore, we are dismissing our decision regarding September 28, 2020 and our decision remains that the Plan does not have to pay for skilled nursing facility services provided on September 29, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the Guardant 360 testing provided on December 22, 2020.

You asked the Plan to pay for the Guardant 360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services rendered were not medically necessary.

The Plan follows Medicare rules. Medicare rules say that Guardant360 testing is only covered for certain indications.

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 the Guardant 360 testing. Our reviewer says that the documentation supports that the services provided were medically reasonable and necessary. Our physician reviewer found the enrollee has invasive bladder cancer. Guardant360 can be used for monitoring and aftercare of a cancer therapy. The documentation support that the enrollee meets criteria for the services rendered.

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 Guardant 360 testing have been met. Therefore, we decided that the Plan has to pay for the Guardant 360 testing provided on December 22, 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 the periodic oral evaluation - established patient (D0120), and the periodontal maintenance (D4910) received November 2, 2020.

You asked the Plan to pay for the periodic oral exam and the periodontal maintenance. You say that the requested services should be covered. The Plan denied your request. The Plan says the requested services processed according to your 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. Periodontal maintenance is not a covered benefit under your plan. In addition, for the oral evaluation, you have been asked to pay the difference between the plan's maximum allowable charge and the amount billed by the out-of-network provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), and the periodontal maintenance (D4910) received November 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxyz HCL tab 25mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested medication is denied as a benefit exclusion.
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-approve Hydroxyz HCL tab 25mg for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for osseous surgery (D4260) provided on November 30, 2020 and January 7, 2021.
You asked the Plan to pay for the osseous surgeries. You say that this service is expensive, and you need further procedures. You say these services are necessary. The Plan denied your request. The Plan says this service is not covered by the Plan's supplemental dental benefit in 2020 or 2021.
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 osseous surgery (D4260) provided on November 30, 2020 and January 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for CT angiography provided on September 11, 2020.

You asked the Plan to waive the co-payment for the CT angiography. You say that you do not have an additional $100 to pay 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 co-payment for CT scan services performed at an outpatient hospital setting.

You have been asked to pay a $100 co-payment for the CT angiography. The CT angiography falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for the CT angiography provided on September 11, 2020.

Your complaint about the hospital performing the CT angiography incorrectly 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of implant services coded 20680 provided on
October 13, 2020.
You asked the Plan to pay for the removal of implant services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 20680 is removal of implant; deep (eg, buried wire, pin,
screw, metal band, nail, rod or plate).
We find that CPT code 20680 is not supported in the medical record. Specifically, the operative report did not
include documentation meet the guidelines of a deep removal of implant (buried wire, pin, screw, metal band,
nail, rod or plate); therefore, this code cannot be verified. Based on this information, we decided that Medicare
rules for coverage of the removal of implant services have not been met. Therefore, we decided that the Plan
does not have to pay for the removal of implant services coded 20680 provided on October 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT), heart provided on
December 28, 2020.
You asked the Plan to pay for the CT, heart. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 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 for a CT, heart provided on December 28, 2020.