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

We decided that the Plan does not have to pre-approve repairs to a power seat elevation system.

You asked the Plan to pre-approve repairs to a seat lift mechanism. You say that the enrollee is paraplegic and requires this. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. 

We looked at the file and Medicare rules. Review of the file shows that the request is for repairs to the enrollee's seat lift elevation system. Since this item is non-covered, repairs to this item is also not covered. Based on this information, we decided that Medicare rules for coverage of repairs to a seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve repairs to a power seat elevation system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gingivectomy or gingivoplasty (D4210).

You asked the Plan to pre-approve the gingivectomy or gingivoplasty. You say that your provider advised that a crown needs to be replaced. You also say that your provider said part of your gums would need to be cut in order to secure the crown. The Plan denied your request. The Plan says this service 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, 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 a gingivectomy or gingivoplasty (D4210).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ultrasound, breast, unilateral, real time with image documentation, including axilla when performed, complete (76641) provided June 2, 2021.

You asked the Plan to waive the copayment for the diagnostic service. You say that you had asked the provider is there was a charge for the ultrasound and was told you there was not charge due to you having dense breasts. The Plan denied your request. The Plan says this claim as processed with the correct copayment applied per the Evidence of Coverage.

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 $50 copayment for each Medicare covered standard x-ray and ultrasound. 

You have been asked to pay $50 copayment for the diagnostic service. The diagnostic service 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 ultrasound, breast, unilateral, real time with image documentation, including axilla when performed, complete (76641) provided June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telephone evaluation you had on March
27, 2021.
You asked the Plan to waive the copayment for the telephone evaluation. You say that you did not have a
telephone evaluation on this date. You said that the office just called you to confirm an appointment that was
scheduled on March 30, 2021. The Plan denied your request. The Plan says you were charged this copayment
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 $10
copayment for telephonic and web-based medical consultations.
You stated that you did not have a telephone consult on this date. However, the medical records from March
27, 2021 clearly show that you had a telephone evaluation with a nurse practitioner to discuss your medications
and the status of a urinary tract infection. Your son was also on the call and reported that you were able to
walk with a walker to the restroom. Therefore, the records confirm that the telephone evaluation occurred. You
have been asked to pay a $10 copayment for the telephone evaluation. The telephone evaluation falls within the telephonic and web-based medical consultations 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 telephone evaluation you had on March 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the cone beam computed tomography (CT)
capture and interpretation (D0364), the root canal (D3320), and the incomplete root canal (D3332) provided
from September 24, 2020, to October 21, 2020.

You asked the Plan to reimburse you for the cone beam CT, root canal, and incomplete root canal. You say that
when you purchased this policy, you were assured that you had dental coverage. You say that you were never
made aware of any changed to the policy from 2019 to 2020. You say that the services you received were
medically necessary. You also say that the services should be covered at 50%. The Plan denied your request.
The Plan says cone beam CT capture with interpretation is not listed as a covered service. The Plan says that
root canal is not listed as a covered service. The Plan says that incomplete root canal 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 cone beam CT, root canal, and
incomplete root canal are not among those covered under this benefit. Therefore, we decided that the Plan does
not have to reimburse you for the cone beam computed tomography (CT) capture and interpretation (D0364),
the root canal (D3320), and the incomplete root canal (D3332) provided from September 24, 2020, to October
21, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the Coronavirus test (U0004) provided on October 12, 2020.

You asked the Plan to pay for the Coronavirus test. You say that you would like this claim to be processed for
payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of
all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the Coronavirus test (U0004) provided on October 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nebulizer and associated supplies (E0570, A7005,
A7015) to be provided by an OON provider.
You asked the Plan to pre-approve the nebulizer kit. You say that the device is medically necessary. The Plan
denied your request. The Plan says it does not dispute that it is medically necessary, but that there are
acceptable in-network alternatives available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
nebulizer and associated supplies (E0570, A7005, A7015) to be provided by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 24 transportation trips (A0120).
You asked the Plan to pre-approve an additional 24 transportation trips. You say that you need additional trips. The Plan denied your request. The Plan says you have utilized 36 of the allowed 48 transportation trips allowed per year and you will 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 48 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 an additional 24 transportation trips (A0120).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 30 transportation trips (A0120).
You asked the Plan to pre-approve an additional 30 transportation trips. You say that you need additional trips. The Plan denied your request. The Plan says you have utilized the maximum number of transportation trips allowed per year.
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 36 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 an additional 30 transportation trips (A0120).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a necessity for you. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested level of care is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you do not require any skilled nursing or rehabilitation services on a daily basis. You are not expected to make measurable gains within a reasonable and predictable period of time or to require skilled therapy to prevent deterioration with mobility or activities of daily living (ADLs). You do not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you do not require any skilled services on an inpatient basis at a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve additional SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the wound care provided from January 6, 2021, to March 29, 2021.

You asked the Plan to waive the copayments for the wound care. You say that you are unable to pay these copayments. 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 $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a total of $2,738.21 for the wound care. The wound care falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 copayments for the wound care provided from January 6, 2021, to March 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit (epoetin alfa-epbx).
You asked the Plan to pre-approve Retacrit. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the provided documentation does not support that the Medicare guidelines have been met.
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 Retacrit. Our reviewer says that the requested drug, Retacrit, is not medically necessary. Our physician reviewer found the requested use of Retacrit is not FDA-approved for the enrollee's diagnosis. The reviewer also found that the use supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal (see appendix for list of CMS-approved journals). Therefore, the reviewer found that Retacrit is not medically reasonable and 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 Retacrit have not been met. Specifically, the files shows that the requested use of Retacrit is not FDA-approved for the enrollee's diagnosis. Therefore, we decided that the Plan does not have to pre-approve Retacrit (epoetin alfa-epbx).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Aduhelm.

You asked the Plan to pre-approve Aduhelm. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested drug have not been met.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Aduhelm. Our reviewer says that the requested drug is not medically necessary in this case. Our physician reviewer found that the Food and Drug Administration has stated that the requested drug is indicated for the treatment of Alzheimer's disease and that treatment should be initiated in patients with mild cognitive impairment or mild dementia stage of disease. In this case, the record indicates that the enrollee has a diagnosis of moderate Alzheimer's-type dementia. The record does not provide an objective assessment of cognitive function. 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 Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Aduhelm.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit and x-rays received on June 3, 
2021, and June 10, 2021. 
 
You asked the Plan to pay for the services. You say that you wanted an x-ray to rule out conditions prior to 
having manipulation of the spine completed. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
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. Therefore, we decided that 
the Plan does not have to pay for a chiropractic office visit and x-rays received on June 3, 2021, and June 10, 
2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from
April 28, 2020, to May 21, 2020.

You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare
Act. The Plan denied your request. The Plan says 100 days of SNF care have already been approved. The Plan
also says that there is no remaining benefit to cover the dates of service in this case.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.

The file shows that the enrollee received 106 days of SNF care during the benefit period from December 18,
2019, to April 27, 2020. The Plan has covered 100 days of SNF care.

Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided
that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from April 28, 2020,
to May 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a
left total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your request.
The Plan says there is no documentation provided to support the expectation the enrollee will require a greater
than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found the enrollee is approved for a left total shoulder arthroplasty. The record
does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or
more midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
November 9, 2020 to November 18, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care. Maximus
overturned the Plans denial because the Plan did not submit an appropriate Plan contract. The Plan requested a
reopen and provided the required Plan contract.
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 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 out of network physician services provided to the enrollee on November 9,
2020 to November 18, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the cost sharing for pulmonary rehabilitation services you received at an 
outpatient hospital facility from January 7, 2020, to January 30, 2020. 
 
You asked the Plan to reduce the cost sharing for the pulmonary rehabilitation services. You say that you 
should only have a copayment of $20 per session for pulmonary rehabilitation. The Plan denied your request. 
The Plan says that you were charged the outpatient hospital cost sharing appropriately. 
 
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 enrollees must pay a $20 copayment per visit for outpatient rehabilitation 
services.  
 
The Plan says you must pay a $225 copayment for the pulmonary rehabilitation services. The Plan contends 
that the copayment for 'Outpatient hospital services- outpatient surgery or procedure' applies here.  We do not 
agree.  You received pulmonary rehabilitation services.  These are neither surgeries or procedures.  Pulmonary 
rehabilitation is a type of outpatient rehabilitation, so the outpatient rehabilitation copayment applies here. 
Based on the Plan contract, you cannot be asked to pay more than a $20 copayment per visit for the pulmonary 
rehabilitation services. Therefore, we decided that the Plan has to reduce the cost sharing for pulmonary 
rehabilitation services you received at an outpatient hospital facility from January 7, 2020, to January 30, 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.