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

We decided that the Plan does not have to pay for removal of torus mandibularis (D7473 x 2) provided to the enrollee on September 9, 2019.
You asked the Plan to pay for the dental services. You say that the services were necessary for the member's dentures to properly fit. The Plan denied your request. The Plan says the member did not purchase the supplemental dental benefit with a dental PPO and dental is not a Medicare covered benefit and excluded from coverage under the Plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for removal of torus mandibularis (D7473 x 2) provided to the enrollee on September 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for scleral gas permeable contact lens (V2531) provided December 19, 2019.
You asked the Plan to pay for the contact lens. You say that this was a medically necessary procedure and you request reconsideration. These scleral lenses effectively reconstructed the exterior of your eyes has drastically improved your vision. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers only covers for an exam and 1 pair of eyeglasses (or contact lenses) for people after cataract surgery.
We looked at the file and the Plan's rules. This service is not covered under the plan benefits. Based on this information, we decided that the Plan's rules for coverage of the contact lens have not been met. Therefore, we decided that the Plan does not have to pay for scleral gas permeable contact lens (V2531) provided December 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided from January 17, 2020 to February 12, 2020.
You asked the Plan to waive the copayment for the SNF services. You say that because you suffered from complications during your stay which caused your stay to be extended that the Plan would cover it. The Plan denied your request. The Plan says that the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $178 copayment for days 21 through 100 of SNF care. You have been asked to pay a $1,068 copayment for the SNF services. The SNF services falls within the days 21 through 100 of SNF 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 the skilled nursing facility (SNF) services provided from January 17, 2020 to February 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy provided by a participating provider on February 1, 2019 to February 28, 2019.You asked the Plan to waive the coinsurance for radiation therapy. You say that you already met your out-of-pocket maximum. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for outpatient hospital services/radiation therapy. You have been asked to pay a 20% coinsurance of the allowed amount for radiation therapy. The total allowed amount is $10,450.20. The total amount you are being asked to pay is $2,090.00 ($10,450.20 x 20% = $2,090.00). Your out-of-pocket maximum had not been met at the time of these services; therefore, the correct coinsurance has been applied. Radiation therapy falls within the outpatient hospital services/radiation therapy 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 radiation therapy provided by a participating provider on February 1, 2019 to February 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care on January 25, 2020.You asked the Plan to waive the copayment forinpatient hospital care. You say that you should not have to owe a second copayment.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 you were discharged from a Skilled Nursing Facility stay and were readmitted for an inpatient hospital stay. You are askedto pay a $295 copayment for the inpatient hospital care. Your EOC states that enrollees must pay a $295 copayment per admission for each medically necessary inpatient stay. 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 forinpatient hospital care on January 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation services provided on January 2, 2020 to January 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for observation services. You say that you would like this claim reprocessed and approved for payment. 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 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 observation services provided on January 2, 2020 to January 3, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional trips to attend medical appointments. The Plan denied your request. The Plan says that you have exceeded your benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of sixty (60) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carvedilol for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee needs a beta blocker for her hypertension. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Carvedilol for the enrollee.
Benefits for this drug 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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for physical therapy services (97161, 97110, 97140) provided for the treatment of temporomandibular joint (TMJ) from February 17, 2020 to February 24, 2020.
You asked the Plan to pay for physical therapy services for the treatment of TMJ. You say that your provider said these services were necessary. The Plan denied your request. The Plan says that treatment for TMJ is not covered.
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and necessary. 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 physical therapy services for the treatment of TMJ. Our reviewer says that the criteria for coverage of these services has been met. Our physician reviewer found the documentation supports that the physical therapy services are primarily focused on a medical condition, that being the limitation and discomfort in jaw motion, rather than being services to treat structures supporting the teeth. Jaw motion and function are being addressed, and no services have been directed to treatment of the teeth. The documentation also supports that the services at issue were medical necessary. The symptoms are common for dysfunction of the TMJ which had a specific initiating event that was documented. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services for the treatment of TMJ have been met. Therefore, we decided that the Plan has to pay for physical therapy services (97161, 97110, 97140) provided for the treatment of temporomandibular joint (TMJ) from February 17, 2020 to February 24, 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 pre-approve filling for crown with posts (D2950) crown-porcelain fused to high noble metal (D6750) Pontic-porcelain fused to high noble metal (D6240) crown-porcelain fused to base metal (D6751) Pontic-cast base metal (D6211).
You asked the Plan to pre-approve the dental services. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says the requested services are not listed as 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 pre-approve filling for crown with posts (D2950) crown-porcelain fused to high noble metal (D6750) Pontic-porcelain fused to high noble metal (D6240) crown-porcelain fused to base metal (D6751) Pontic-cast base metal (D6211).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve the IRF admission. You say that the enrollee would benefit from this care. The Plan denied your request. The Plan says that there is no evidence that this level of care is required.
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 has not submitted any records to support its denial of these services. The only documentation provided are incomplete screenshots of the pre-screen admission form. Without the medical records the Plan reviewed to make its decision, MAXIMUS is not able to perform an independent review. We find that it is not in the enrollee's best interest to extend the time frame and delay a decision in order to request these records from the Plan. Therefore, we decided that the Plan has to pre-approve admission to an inpatient rehabilitation facility (IRF).
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: Imaging
Decision: Favorable

We decided that the Plan has to pay fora chest x-ray (71045) provided on February 7, 2020.You asked the Plan to pay forthe chest x-ray. You say that you would like reconsideration because this member had multiple exams on the same day.The Plan denied your request. The Plan says that the services on this claim have already been processed and paid.The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have been met. Specifically, the record indicates that the services in question were rendered by different providers. This is not a duplicate claim.Therefore, we decided that the Plan has to pay fora chest x-ray (71045) provided on February 7, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing provided on November 7, 2019.You asked the Plan to pay for train of four testing. You say that intraoperative monitoring during surgery was necessary to minimize the risk of post-operative deficits.The Plan denied your request. The Plan says the service is a bundled procedure included in the cost of the primary procedure.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 looked at the file and the rules. The train of four testing was provided during intraoperative neuromonitoring services. The train of four testing is bundled into payment for the related neuromonitoring services. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing provided on November 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scans provided on February 6,
2020.
You asked the Plan to waive the copayment for the CT scans. You say that you are being charged for 3
different scans. You say that you should only have one copayment. The Plan denied your request. The Plan
says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175
copayment for each Medicare-covered advanced imaging service.
You have been asked to pay a total of $525 for the CT scans.

The CT scans 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 copayment for the CT scans provided on February 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the enrollee on December 26, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) G0482 remains not supported.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 G0482 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found based on the medical records provided the documentation does not support the coding of HCPCS G0482. No documentation of a medical relationship between the provider and the enrollee were presented.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 services have not been met.Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the enrollee on December 26, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided to the enrollee from February 25, 2020 to February 28, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the enrollee is in a basic transfer/ambulation program, which does not require the skills of a physical therapist.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the therapy from February 25, 2020 to February 28, 2020 is generally not accepted as specific and effective therapy for the enrollee's condition. The enrollee had reached a functional level that no longer required the skills of a professional therapist. Her functional level did not need the ongoing unique skills of a professional therapist to safely and effectively provide treatment. Services did not only need to be safely and effectively performed by a therapist, or under the supervision of a therapist. The requested services were not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services provided to the enrollee from February 25, 2020 to February 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80048 and 85027 provided on December 10, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 80048 and 85027 are not supported in the medical record. Specifically, codes 80048 and 85027 were both billed with modifier 26. Codes 80048 and 85027 are not eligible for separate reimbursement in place of service 22 (on-campus outpatient hospital) and modifier 26 is not appropriate for procedure codes 80048 and 85027. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80048 and 85027 provided on December 10, 2019.