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

We decided that the Plan does not have to pre-approve Xiidra.
You asked the Plan to pre-approve Xiidra. The Plan denied your request. The Plan says this is not a covered
benefit.
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 Xiidra.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom prefabricated abutment (D6057), and abutment
supported crown (D6058) for tooth # 4.
You asked the Plan to pre-approve the dental services. You say that your tooth fell out. You say that the hole is
affecting your speech and ability to chew food. You also say that if you chew on that side of your mouth you
have pain. The Plan denied your request. The Plan says custom 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 requested custom prefabricated
abutment and abutment supported crown are not among those covered under this benefit. Therefore, we
decided that the Plan does not have to pre-approve custom prefabricated abutment (D6057), and abutment
supported crown (D6058) for tooth # 4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extractions, implants, and dentures.
You asked the Plan to pre-approve the dental services. You say that the requested services are needed as a result of the medication you are on. You also say that these services would be a hardship for you. The Plan denied your request. The Plan says the requested services are routine dental in nature. The Plan says that the requested services are not being requested as a result of an accidental injury or congenital anomaly.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve extractions, implants, and dentures.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve an office visit. You say that the enrollee needs to see a specialist for their
pain. The Plan denied your request. The Plan says a list of in-network providers was given where the enrollee
can use.
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
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on September 27, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on September 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for portable x-ray transportation (R0070) provided July 15, 2021.
You asked the Plan to pay for the portable x-ray transportation. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim does not meet coding standards and cannot be paid.
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 code R0070 is not supported in the medical record. Specifically, the portable x-ray transportation service was billed without a corresponding portable x-ray setup code.
Based on this information, we decided that Medicare rules for coverage of the portable x-ray transportation have not been met. Therefore, we decided that the Plan does not have to pay for portable x-ray transportation (R0070) provided July 15, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pre-approve computed tomography (CT) of the right knee for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the medical studies do not support the use of a computed tomography (CT) scan to plan robotic total knee arthroplasty.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the Mako device will be used for the planned robotic assisted arthroplasty. This device requires software obtained through the computed tomography (CT) scan. Thus, since Mako robotic assisted arthroplasty is planned the requested CT will be medically necessary for the surgeon to use the device for the procedure.
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 scan have been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of the right knee for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health therapy services (G0151, G0153).

You asked the Plan to pre-approve home health therapy services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee no longer needs therapy services.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 home health therapy services. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the documentation does not support that the enrollee requires additional skilled rehabilitation services. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health therapy services (G0151, G0153).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) to be provided
by an out-of-network (OON) provider.
You asked the Plan to pre-approve the MRI. You say that the service is medically necessary. The Plan denied
your request. The Plan says the provider is 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 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
the magnetic resonance imaging (MRI) to be provided 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 services (97010) provided on July 15, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. We looked at the file and Medicare rules. Code 97010 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for code 97010. 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 the services (97010) provided on July 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on August 3, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or
proprietary laboratory analysis CPT code.

We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 the genetic testing provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on August 30, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.

We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services
were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion
therapy rendered on August 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on September 6, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 

We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on September 6, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of SNF care from February 15, 2022, forward.  You asked the Plan to pre-approve SNF care. You say that you do not feel the enrollee should be billed for any days after today as it is not their fault the screening was not done on Friday. The Plan denied your request. The Plan says the stay 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 the enrollee no longer qualifies for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than one hundred (100) feet and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of care.  Furthermore, you have asked the Plan to waive any cost-sharing that may be applied for these services when they are provided. Maximus Federal Services cannot review requests related to cost-sharing for services that have not yet taken place. Your complaint is a grievance that must be answered by the Plan directly.  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 continuation of SNF care from February 15, 2022, forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88312) provided September 27, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

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 code 88312 is not supported in the medical record. Specifically, the medical records provided do not meet Medicare requirements for the billing of Special Stains. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (88312) provided September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110) provided March 30, 2021.

You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the claim cannot be paid as billed.

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 code 97110 is not supported in the medical record. Specifically, the records show this service
was provided in the home by an assistant. There is a more appropriate code for this service (G0157). Based on
this information, we decided that Medicare rules for coverage of the therapy services have not been met.
Therefore, we decided that the Plan does not have to pay for therapy services (97110) provided March 30,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Synvisc injection 1mg provided on
October 18, 2021.
You asked the Plan to waive the coinsurance for the Synvisc injection 1mg. You say that the services should be
covered as they are expensive. The Plan denied your request. The Plan says the coinsurance applied correctly
based on the services 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 20%
coinsurance for Medicare Part B non-chemotherapy prescription drugs, and the administering of them.
You have been asked to pay a 20% coinsurance for a Synvisc injection 1mg (allowed is $539.52 x 20% =
$107.90). Synvisc injections fall within the Medicare Part B prescription drugs 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 a Synvisc injection 1mg provided on October 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pathology services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve pathology services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says there are in-network provider who are available to fulfill your request within a reasonable distance from your location.
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 pathology services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266) for tooth # 30, and bone replacement graft (D4263) for tooth # 30.

You asked the Plan to pre-approve the dental services. You say that the tooth roots are now gone. You say that the crown has nothing to hold onto. You also say that you cannot eat because of this situation. The Plan denied your request. The Plan says guided tissue regeneration is not listed as a covered service. The Plan says bone replacement graft 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 requested guided tissue regeneration and bone replacement graft are not among those covered under this benefit.

Therefore, we decided that the Plan does not have to pre-approve guided tissue regeneration (D4266) for tooth # 30, and bone replacement graft (D4263) for tooth # 30.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) provider on October 7, 2021.  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 was rendered by an out of network provider, without 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 service 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 this service. Therefore, we decided that the Plan does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) provider on  October 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient behavioral health admission provided from
April 6, 2021, through June 9, 2021.
You asked the Plan to pay for the inpatient behavioral health admission. The Plan denied your request. The Plan says no prior authorization was obtained.
The Plan contact says that covered services include mental health care services that require a hospital stay. Authorization rules may apply.
We looked at the file and the Plan's rules. The file shows that authorization was required and not obtain for these services. Therefore, we decided that the Plan does not have to pay for inpatient behavioral health admission provided from April 6, 2021, through June 9, 2021.