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

We decided that the Plan does not have to pre-approve the extra heavy-duty wheelchair (K0007).
You asked the Plan to pre-approve the extra heavy-duty wheelchair. You say that this service is necessary for the enrollee's condition. The Plan denied your request. The Plan says considering the member's weight, Medicare recommends a different wheelchair.
The Plan must follow Medicare rules. Medicare rules say that an extra heavy-duty wheelchair is covered if the beneficiary weighs more than 300 pounds. We looked at the file and Medicare rules. The information in the case file indicates that the enrollee is currently not over 300 pounds. Based on this information, we decided that Medicare rules for coverage of the extra heavy duty wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve the extra heavy-duty wheelchair (K0007).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services received on October 6, 2020.
You asked the Plan to pay for the dental services. You say that you would like the plan to reconsider their decision. The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.
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. The Plan covers the dental services up to an annual maximum of $2,500. We looked at the file and Medicare rules. Review of the file shows that you had already received dental services prior to October 5, 2020 for a total of $480 and then on October 5, 2020 you received dentures for a total of $1,557. Leaving a balance of $470.20 of your maximum benefit. The dental services received on October 6, 2020 were a total of $1,412. Therefore, you owe the difference in balance of $941.80. The services received on October 6, 2020 Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for the dental services received on October 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the surgery and laboratory services received on July 20, 2020, to waive the copayment for the outpatient surgery and to pay for the self-administered drugs received on July 31, 2020.
You asked the Plan to waive the deductible for the surgery and laboratory services, to waive the copayment for the outpatient surgery and to pay for the self-administered drugs. You say that you would like the plan to reconsider their decision. The Plan denied your request. The Plan says the claims have been processed correctly per your plan 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). Your contract with the Plan clearly says that you must pay a $500 deductible that you must pay out of pocket before the plan will pay their share for your covered medical services from in-network or out-of-network providers. Your contract with the Plan also clearly states that you must pay a $250 copayment for outpatient surgery services. The rules also 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. You have been asked to pay a $500 deductible for the surgery and laboratory services, to waive the copayment for the outpatient surgery and to pay for the self-administered drugs. The surgery and laboratory services received on July 20, 2020 fall within the deductible benefit category. The outpatient surgery falls within the outpatient surgery 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. In addition, 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 waive the deductible for the surgery and laboratory services received on July 20, 2020, to waive the copayment for the outpatient surgery and to pay for the self-administered drugs received on July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care services.

You asked the Plan to pre-approve personal care services. You say that your daughter has been your home aide
for over a year. The Plan denied your request. The Plan says the services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy. Custodial care is not covered.

We looked at the file, and Medicare rules. The services you are asking the Plan to pre-approve are considered
custodial care. 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 pre-approve personal care services.

Please note that our decision is only about your Medicare benefits. Maximus does not have jurisdiction with
regard to Medicaid benefits. Please contact the Plan to find out how to file an appeal of the denial of Medicaid
benefits.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Stereotactic Body Radiation Therapy.
You asked the Plan to pre-approve Stereotactic Body Radiation Therapy. You say that the enrollee would be an excellent candidate for SBRT rather than putting her through systematic therapy for involvement of a single node, which would carry significantly more toxicity than SBRT. The Plan denied your request. The Plan says that guidelines do not support the routine use of the requested type of treatment (therapy) for the enrollee's cancer type.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 pre-approve Stereotactic Body Radiation Therapy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found although the primary treatment for most patients with metastatic cancer is systemic therapy, stereotactic body radiation therapy (SBRT) is being evaluated in those with few metastatic sites (oligometastatic disease). In a meta-analysis of 21 prospective studies including over 900 patients with oligometastatic cancer receiving SBRT to various sites, the rates of local control and overall survival at one year were 85 percent and 95 percent, respectively. Survival rates were similar in a registry-based study of over
1400 patients receiving SBRT for oligometastatic disease. This enrollee fits this criteria and the use of SBRT is reasonable and 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 Stereotactic Body Radiation Therapy have been met. Therefore, we decided that the Plan has to pre-approve Stereotactic Body Radiation Therapy.
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 medical services received on a cruise ship from April 27,
2018, to April 29, 2018.
You asked the Plan to pay for the services. You say that you should be reimbursed. The Plan denied your
request. The Plan says this was submitted past the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the services was not filed until October 28, 2019. This means that more than
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the
Plan does not have to pay for medical services received on a cruise ship from April 27, 2018, to April 29, 2018.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio (J3380).
You asked the Plan to pre-approve Entyvio. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria has not been met.
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 Entyvio. Our reviewer says that the request for Entyvio does not meet step therapy requirements. Our physician reviewer found the enrollee has not tried and failed the required step therapy alternatives and there is no indication that these drugs would be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio (J3380).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for three pontics (D6210 x2 and D6240 x1) and six retainer crowns (D6750 x6).
You asked the Plan to pay for the pontics and retainer crowns. You say that you would like to appeal these services. 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 three pontics (D6210 x2 and D6240 x1) and six retainer crowns (D6750 x6).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 2, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab services. You say that you were homebound and unable to leave the home to have testing. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not 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 had network providers available who could have provided 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 medical services provided on June 2, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308)
provided on April 29, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service is not payable as the claim was
submitted untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for this service was not filed until September 1, 2020. This means that more than
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the
Plan does not have to pay for the subsequent nursing facility care, per day (99308) provided on April 29, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician services provided on October 31, 2020, and billed under code
98941-AT.
You asked the Plan to pay for these services. You say that this claim should be paid, and you have been having
issues with your chiropractic services being paid correctly. The Plan denied your request. The Plan says that
this claim was billed with an inappropriate code by the provider.
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. There were no claims or medical records submitted with the case
file. Maximus requested additional information from the Plan and that request was not responded to. As the
enrollee, you have no control over how the claim is billed and the Plan must make efforts to hold you harmless
for this error other than your normal copayment expectation. The Plan has not provided enough information to
substantiate its denial. Therefore, we decided that the Plan has to pay for physician services provided on
October 31, 2020, and billed under code 98941-AT.
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: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on September 12, 2020.

You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the charges and cannot afford them. 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 a $0 copayment for mammograms or ultrasounds and a $150 copayment for all other diagnostic and nuclear medicine radiological services. 

You have been asked to pay a $150 copayment for a CT scan. A CT scan 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 a CT scan provided on September 12, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance transportation service (A0425, A0429) provided on April 22, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the service is not payable as they are the secondary insurer in this case.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has not met its obligation with regards to the coordination of benefits. Specifically, the claim was denied by the party indicated as the primary insurer in this case. Therefore, we decided that the Plan has to pay for the ambulance transportation service (A0425, A0429) provided on April 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the inpatient rehab level of intensive therapy exceeds member's need.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness and aphasia. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genomic sequence analysis (0037U) provided on July 20, 2020.

You asked the Plan to pay for genomic sequence analysis. You say that this is a Medicare-covered benefit. The Plan denied your request. The Plan says the enrollee previously received testing for the same indication.

The Plan must follow Medicare rules. Medicare rules say that Next Generation Sequencing (NGS) is covered if the enrollee not been previously tested with the same test using NGS for the same cancer genetic content.

We looked at the file and Medicare rules. The record shows that the enrollee previously received testing for the same cancer indication. Based on this information, we decided that Medicare rules for coverage of genomic sequence analysis have not been met. Therefore, we decided that the Plan does not have to pay for genomic sequence analysis (0037U) provided on July 20, 2020.
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 the enrollee meets criteria for the IRF care. The Plan denied your request. The Plan says IRF care is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, it is my opinion that the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of 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 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: 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 this is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the records provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of 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 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.