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

We decided that the Plan does not have to waive the copaymentfor the computed tomography (CT) scan of the thorax (71250) provided on September 23, 2020.You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.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 $150 copayment for advanced imaging services. You have been asked to pay a $150 copayment for the advanced imaging service provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. Additionally, on this day, two separate imaging services were provided by different physicians; therefore, you are responsible for the copayment that applies to each claim.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 copaymentfor the computed tomography (CT) scan of the thorax (71250) provided on September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 26, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vibration therapy services provided on January 15, 2021.
You asked the Plan to pay for the services provided. You say that you never had mechanical traction. The Plan denied your request. The Plan says the plan only covers manual manipulation of the spine to correct subluxation.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Services other than manual manipulation of the spine, when performed by a chiropractor, are not covered. Therefore, we decided that the Plan does not have to pay for the vibration therapy services provided on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the prefabricated abutment (D6056), and the abutment supported crown (D6059) provided on January 14, 2021.

You asked the Plan to reimburse you for the dental services. You say that you paid for these services out of pocket. You also say that the services should be covered. The Plan denied your request. The Plan says prefabricated abutment is not listed as a covered service. The Plan says that abutment supported crown is not listed as a covered service either.

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 prefabricated abutment and the
abutment supported crown are not among those covered under this benefit. Therefore, we decided that the Plan
does not have to reimburse you for the prefabricated abutment (D6056), and the abutment supported crown
(D6059) provided on January 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trastuzumab-dkst.
You asked the Plan to pre-approve Trastuzumab-dkst. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says single agent use of Trastuzumab-dkst is not supported for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Trastuzumab-dkst. Our reviewer says that the requested drug service is not medically reasonable and necessary. Our physician reviewer found in this case, the enrollee has triple positive invasive ductal breast cancer. She underwent lumpectomy. The requested drug is being used as a single drug regimen. The Medicare approved cancer compendia do not provide support for this regimen for the noted indication. The prescriber submitted an article with the request. The results reported are not sufficiently supportive of the noted indication. The requested drug is not medically necessary and reasonable as defined by Medicare rules for the noted diagnosis. 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 Trastuzumab-dkst have not been met. Therefore, we decided that the Plan does not have to pre-approve Trastuzumab-dkst.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the colonoscopy provided on January 18, 2021.
You asked the Plan to reduce the copayment for the colonoscopy. You say that the facility is the only provider
who could perform the colonoscopy. You say you would like the claim covered at the preferred rate. 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 $440
copayment per visit for outpatient procedures and services, including but not limited to diagnostic and
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center.
You have been asked to pay a $440 copayment for the colonoscopy. The colonoscopy falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The record shows the facility is considered a non-preferred provider.
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 reduce the copayment for the colonoscopy provided on January 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the $41.47 coinsurance charged for a walking boot provided on November 26, 2020.
You asked the Plan to waive or reduce this coinsurance. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost share was charged based on the claim submitted by your provider and the Plan contract agreement. Maximus partially overturned the Plans denial stating your coinsurance should have been 10% of the cost. The Plan requested a reopen and stated the Evidence of Coverage or Plan contract submitted with the original case file was not for the Plan you are enrolled in. The Plan provided a copy of the correct contract with the reopen request.
Review of the correct Plan contract shows the Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment. 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 or reduce the $41.47 coinsurance charged for a walking boot provided on November 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Soliris (J1300) to be given at home.
You asked the Plan to pre-approve Soliris. You say that the enrollee fatigues easily. You also say that she has a
cane but does not use it frequently. The Plan denied your request. The Plan says before this drug is covered for
use in the enrollee's home, the provider must confirm that the enrollee is confined to their home. The Plan says
that information was requested but not received. The Plan also says that without documentation showing that
the enrollee is confined to their home, this cannot be approved.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, the provider is requesting the drug be administered in the enrollee's home via home infusion. Since
the medication does not represent an expense to the physician and will not be included in the physician's bill, it
is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Soliris
(J1300) to be given at home.
Benefits for Soliris 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora diagnostic CT scan providedby a participating provider on March 6, 2021.You asked the Plan to waive the copayment fora diagnostic CT scan. You say that you have never had to pay for this before. You say that you get this done because you were a smoker.The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly saysthat you must pay a $50 copayment for outpatient diagnostic tests/diagnostic radiological procedures. ou have been asked to pay a $50 copayment for a diagnostic CT scan. The CT scan that was provided was diagnostic in nature; therefore, the correct copayment has been applied. A diagnostic CT scan falls within the outpatient diagnostic tests/diagnostic radiological procedures 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 fora diagnostic CT scan provided by a participating provider on March 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on February 23, 2021 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.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 foran office visit provided on February 23, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom fabricated abutment (D6057) and porcelain/ceramic crown on implant (D6058).
You asked the Plan to pre-approve custom fabricated abutment and porcelain/ceramic crown on implant. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are not 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 custom fabricated abutment (D6057) and porcelain/ceramic crown on implant (D6058).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for occupational therapy provided on November 19, 2019 and December 18, 2019.
You asked the Plan to waive the copayment for the occupational therapy. The Plan denied your request. The Plan says the enrollee is responsible for a $10.00 copayment for the therapy services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $10 copayment for outpatient rehabilitation services, occupational therapy.
The enrollee has been asked to pay a $10 copayment for the occupational therapy. The occupational therapy falls within the outpatient rehabilitation services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for occupational therapy provided on November 19, 2019 and December 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, each additional intraoral periapical x-ray, localized delivery of antimicrobial agents, and periodontal maintenance provided on February 23, 2021.
You asked the Plan to pay for the intraoral periapical x-rays, localized delivery of antimicrobial agents, and periodontal maintenance. You say that you would like help paying this dental bill. 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 first intraoral periapical x-ray, each additional intraoral periapical x-ray, localized delivery of antimicrobial agents, and periodontal maintenance provided on February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on January 20, 2021 by an out of
network (OON) provider.

You asked the Plan to pay for the OON services. You say that the physician depends on the hospital staff to
obtain the proper authorization. The Plan denied your request. The Plan says services rendered by nonparticipating
provider require prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the rest home visit provided on January 20, 2021 by an out of network (OON)
provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on March 5, 2021.
You asked the Plan to waive the copayment for emergency care. You say that this was a scheduled appointment for a computerized tomography scan and not an emergency room visit. 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 $90 copayment for emergency care. The record shows that you received emergency care on March 5, 2021. Therefore, you are responsible to pay
the $90 copayment. Please note that this is cheaper than the advanced imaging copayment. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on March 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and paid. You say that these services were medically necessary. The Plan denied your request. The Plan says prior authorization is required for out-of-network providers. The Plan says that prior 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 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 an office visit provided on December 3, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740), and a core buildup (D2950) provided on February 2, 2021.
You asked the Plan to pay for a crown, and a core buildup. You say that the services at issue should be covered. The Plan denied your request. The Plan says the services at issue are not covered 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. 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 a crown (D2740), and a core buildup (D2950) provided on February 2, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the porcelain/ceramic crown (D2740) and core buildup (D2950) provided for tooth #5 on September 24, 2020.
You asked the Plan to pay for the crown and core buildup. You say that this tooth presented with recurrent decay and sensitivity. These services were necessary. The Plan denied your request. The Plan says that these services were not medically necessary.
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 crown and core buildup when the services are medically necessary and reasonable. 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 crown and core buildup. Our reviewer says that the criteria for coverage for a crown and core buildup on tooth #5 have been met. Our physician reviewer found the dental record and x-rays provided indicate that tooth #5 contained a large restoration with recurrent caries. The enrollee was symptomatic with sensitivity. The caries and remaining restoration were removed, and a core buildup and crown were placed to provide good functional occlusion. It is our reviewer's opinion that these services were medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown and core buildup have been met. Therefore, we decided that the Plan has to pay for the porcelain/ceramic crown (D2740) and core buildup (D2950) provided for tooth #5 on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial observation care provided on January 30, 2021 by an out of network provider.

You asked the Plan to pay for initial observation care (99220). You say that the enrollee was seen through the ER and evaluated by our physician for medically necessary services. The Plan denied your request. The Plan says you did not request prior authorization.

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 services at issue in this appeal. The Plan did not pre-approve the service 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 initial observation care provided on January 30, 2021 by an out of network provider.