Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on March 3, 2021.

You asked the Plan to waive the copayment for urgently needed services. You say that you feel that the services should not be considered urgent care services because all they did was take your blood pressure. 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 $50 copayment for urgently needed services. 

You have been asked to pay a $50 copayment for urgently needed services. Urgently needed services fall within the urgently needed services 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 urgently needed services provided on March 3, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the magnetic resonance imaging (MRI), spinal canal and contents (72141).

You asked the Plan to pre-approve the MRI. You say that the medical records provided support the necessity of the services. The Plan denied your request. The Plan says that there is no record (in person, by phone, mail or messaging) that the enrollee had contact with their doctor after a recent (within three months) six-week trial of treatment that failed to improve their symptoms.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer found in this case the enrollee was noted to have had upper extremity weakness, with symptoms greater in one arm more than the other. A process such as cervical radiculopathy would therefore be within the differential diagnoses in such a presentation. The enrollee is also noted to have PFT findings consistent with restrictive lung disease. In such a setting there is a possibility of a neurological etiology for said symptoms which could partially be evaluated with advanced imaging. In such a context, given the differential diagnoses, an imaging study as requested would fall within the scope of being 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 the MRI have been met. Therefore, we decided that the Plan has to pre-approve the magnetic resonance imaging (MRI), spinal canal and contents (72141).

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 22, 2021, by an OON
provider.
You asked the Plan to pay for the services provided. You say that the lab does not receive enrollee information
until after services are rendered. The Plan denied your request. The Plan says the services were not urgent,
emergent, or approved in advance.
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 lab services provided on March 22, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an oral cancer screening (D0431) provided on June 9, 2021.
You asked the Plan to pay for an oral cancer screening. You say that you did not authorize the service at issue and only wanted the provider to perform covered services. The Plan denied your request. The Plan says the requested service is not covered under the supplemental dental 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 service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an oral cancer screening (D0431) provided on June 9, 2021.
Your complaint about receiving services from the provider that you did not authorize is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a change in oxygen supplier for traveling.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requested item is a duplicate service.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home and is being requested for traveling. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a change in oxygen supplier for traveling.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic spinal manipulation (98941) and therapeutic procedures (97139) provided from April 26, 2021, to May 3, 2021.

You asked the Plan to pay for chiropractic spinal manipulation and therapeutic procedures. You say that you should be reimbursed for these services. The Plan denied your request. The Plan says these services processed 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 40% coinsurance for out-of-network covered chiropractic services. The rules also say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

You have been asked to pay a 40% coinsurance for chiropractic spinal manipulation provided by an out-of-network 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. The therapeutic procedures at issue are not manual manipulation of the spine, meaning they are not covered. Therefore, we decided that the Plan does not have to pay for chiropractic spinal manipulation (98941) and therapeutic procedures (97139) provided from April 26, 2021, to May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on May 13, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that you rely on the facility to obtain authorization. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
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 psychotherapy services provided on May 13, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 2, 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 supported.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at this the file and Medicare rules. There is no documentation to support the testing billed with code
U0003 is separate from the approved testing. The services are considered mutually exclusive. Based on this
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we
decided that the Plan does not have to pay for the laboratory services rendered on June 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on May 8, 2021.
You asked the Plan to pay for the ambulance treatment without transport. You say that you do not understand why you are being billed more than your expected copay for these services. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit, and without transportation there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 8, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Documentation shows that you were advised to seek further medical evaluation in the emergency room but declined transport at the time as you were feeling better. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on May 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve apheresis.

You asked the Plan to pre-approve apheresis. You say that this procedure is a treatment of last resort for the enrollee and has been approved by the Food & Drug Administration for this diagnosis. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because lowering lipids is not a covered indication for this procedure.

The Plan follows Medicare rules. Medicare rules say that apheresis is only covered under certain conditions. 

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 apheresis. Our reviewer says that the enrollee does not meet the Medicare criteria for apheresis. Our physician reviewer found the apheresis criteria do not include elevated low-density lipoprotein or lipoprotein(a). While this is an intriguing therapy for the enrollee, it is not on the list of Medicare-approved diagnoses for apheresis. Smoking cessation and better diet would seem to be in order for this high-risk patient. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of apheresis have not been met. Therefore, we decided that the Plan does not have to pre-approve apheresis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant /abutment supported removable denture for
edentulous arch - mandibular (D6111).

You asked the Plan to pre-approve a removable lower denture. You say that your dentist says this is the only
feasible option for your situation. The Plan denied your request. The Plan says this service is not covered under
your 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 pre-approve an
implant /abutment supported removable denture for edentulous arch - mandibular (D6111).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from May 24, 2021, to May 28, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were in the hospital from May 24, 2021, to May 28, 2021, which is not 7 days. 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 $325 copayment for days 1-6 for inpatient hospital care. 

The medical records show that you had an inpatient hospital stay from May 21, 2021, to May 28, 2021. However, you are only being asked to pay a $325 copayment for 4 days. Therefore, the total amount you owe is: $1,300. 

You have been asked to the total copayment amount of $1,300 for an inpatient hospital stay. An inpatient
hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided from May 24, 2021, to May 28, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on April 2, 2021.

You asked the Plan to waive the copayment for emergency care. You say that a catheter was misplaced at a previous emergency room visit and you had to return the next morning. 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. 

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 April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the negative pressure wound therapy (97605) and the foam dressing (A6212) rendered by the out-of-network (OON) provider from May 21, 2021, through May 28, 2021.

You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the items/services were 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 items/services at issue in this appeal.

The Plan did not pre-approve the items/services 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 negative pressure wound therapy (97605) and the foam dressing (A6212) rendered by the out-of-network (OON) provider from May 21, 2021, through May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Apligraf skin substitute wound treatments.

You asked the Plan to pre-approve Apligraf skin substitute wound treatments. You say that Apligraf skin
substitute wound treatments are medically necessary. The Plan denied your request. The Plan says Medicare
coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided
additional information.

Our Medical Director reviewed the case file and the reopen request. At issue is coverage for Apligraf skin
substitute. The Maximus Physician Reviewer determined that the requested services are considered medically
reasonable and necessary in this case. The reviewer found that the wound does not heal and may lead to
osteomyelitis. The Plan requested a reopen and argues that the diagnosis is osteomyelitis and treatment was
being given with antibiotics. The Plan states the records show a skin substitute would not be reasonable to
apply with an active infection.

The medical records show a diagnosis of a Non-pressure chronic ulcer of the right ankle with fat layer exposed.
The medical history is notable for diabetes, peripheral vascular disease, and hypertension. The records show
lateral malleolar ulcer on the right lower extremity that has been non-healing, due to repeated unintentional
trauma and recurrent infection. The was underlying osteomyelitis in the right malleolus. There was necrotic
debris on the lateral ulcer bed and the wound was debrided.

Our Medical Director has concluded that the Plan is correct in this case. Apligraf is a bi-layered skin substitute.
Apligraf is contraindicated for use on clinically infected wounds. The records show a clinically infected wound
was present. Therefore, Medicare coverage criteria were not met. We looked at this physician's review, the file,
and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Apligraf skin
substitute wound treatments have not been met. Therefore, we decided that the Plan does not have to preapprove
Apligraf skin substitute wound treatments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and cone beam
computed tomography (CT) image capture with field of view of both jaws (D0383) provided on June 25, 2021
by a Medicare opt out provider.

You asked the Plan to pay for the comprehensive oral evaluation and cone beam CT image capture. You say
that this was a medical examination of your tongue and should be handled as a medical claim. The Plan denied
your request. The Plan says these services are not allowed because they were performed by a provider who has
chosen to opt out of Medicare. The Plan also says that you are responsible for the amount you negotiated with
your provider.

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
covered when they are received by a Medicare opt out provider. The record shows that the Plan was told by the
provider that you were given the statement of $240.00 because the provider is not contracted with Medicare,
and also said you were verbally advised of this. Therefore, we decided that the Plan does not have to pay for
the comprehensive oral evaluation (D0150) and cone beam computed tomography (CT) image capture with
field of view of both jaws (D0383) provided on June 25, 2021 by a Medicare opt out provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 4 wheeled scooter.
You asked the Plan to pre-approve a 4 wheeled scooter. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 a 4 wheeled scooter. Our reviewer says that the item is not medically necessary. Our physician reviewer found the enrollee has a mobility deficit and currently uses a 3 wheeled scooter. The documentation does not reveal that the enrollee is unable to complete his mobility related activities of daily living (MRADLs) with his current mobility device. There is no evidence of a detailed home evaluation that indicates the requested 4 wheeled scooter could be safely operated in the home.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a 4 wheeled scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a 4 wheeled scooter