Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay for dental services provided from December 28, 2020,
to December 29, 2020.
You asked the Plan to pay for these services. You say that your policy for 2020 covers up to $4,000 for
dental services. You say that the Plan has only paid $3,794.20. You also say that there is a remaining balance
of $205.80. The Plan denied your request. The Plan says there is a $4,000 yearly allowance for covered
preventive and comprehensive dental services combined. The Plan also says that the annual allowance has been
exhausted. Maximus overturned the Plans decision. The Plan requested a reopen and provided additional
information. The Plan says that you elected coverage from the Plan under contract H3959-036 from January 1,
2020, through March 31, 2020, and September 1, 2020, through January 31, 2021. As an enrollee eligible for
both Medicare and Medicaid, you are permitted to change insurance plans once every quarter for the
first 3 quarters of the year. However, since you initially enrolled in contract H3959 036 and later returned to
H3959 036 within the same calendar year from January 1, 2020, to December 31, 2020, you are only entitled
to receive the maximum benefit of $4000 for non-Medicare covered dental services in accordance with the
H3959-036 contract. Medicare guidelines are clear that the cap for a supplemental benefit can only be imposed
at the Plan level. The records show the Plan has paid $4000 for your dental services in 2020.
The Plan is correct in the case. 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 more than Medicare coverage, based on the documentation provided,
that benefit was exhausted prior to the dates of service in question. Therefore, we decided that the Plan does not
have to pay for to pay for dental services provided from December 28, 2020, to December 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Shower Buddy shower chair.
You asked the Plan to pre-approve shower chairs or equipment of any kind. You say that a shower chair is medically necessary for safety. The Plan denied your request. The Plan says shower chairs and equipment are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a Shower Buddy shower chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tramadol HCL.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Tramadol HCL.
Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.
You asked the Plan to pre-approve the requested services. You say that without the procedure, the enrollee will be in pain. The Plan denied your request. The Plan says the request does not meet the criteria.
The Plan must follow Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications
We looked at the file and Medicare rules. The records show that radiofrequency ablation in the cervical region were provided on January 18, 2021, and February 8, 2021. For each covered spinal region, no more than 2 radiofrequency sessions will be reimbursed per rolling 12 months. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798) provided on September 21, 2020.

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 as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate place of service 11. According to claims history, the specimen was obtained in a Skilled Nursing Facility POS 31. Therefore, we decided that the Plan does not have to pay for the laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798) provided on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided on May 13, 2021.

You asked the Plan to pay for the therapy 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 as billed.

The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services.

Therefore, we decided that the Plan does not have to pay for the therapy services provided on May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0481) provided December 21, 2020.
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 services 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 G0481 is not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). 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 (G0481) provided December 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an arthroscopy of the knee (29881). 
 
You asked the Plan to pre-approve an arthroscopy of the knee. You say that the requested procedure is a 
medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the 
requested procedure have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 an arthroscopy of the knee. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that detailed documentation is not evident regarding trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures. In addition, there are no imaging 
studies provided for review to corroborate any meniscal pathology for which the requested procedure would be 
indicated. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an arthroscopy of the knee have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an arthroscopy of the knee (29881).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Esbriet 801 mg tablet.
You asked the Plan to pre-approve Esbriet. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 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 Esbriet 801 mg tablet.
Benefits for Esbriet 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 23, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered.  
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical 
therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private 
practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that 
NP/PA may perform physical therapy services under State law.  
 
We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the 
physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide 
physical therapy in the State of Arizona. The multiple drug codes reported on this claim refer to a pre-filled 
compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not 
otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. 
Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. The office 
visit at issue was billed with modifier 25, which is used to report a significant, separately identifiable 
Evaluation and Management (EM) service by the same physician or other qualified health care professional on 
the same day of a procedure or other service. There is no documentation of any significant, separately 
identifiable evaluation unrelated to the treatment provided to the enrollee on this date of service. 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 provided on February 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you feel unsafe to go home. The Plan denied
your request. The Plan says that you do not meet this level of care.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF services.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on June 21, 2021. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. The Plan denied your request. The 
Plan says this service is not a covered benefit under your dental plan. 
 
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 
comprehensive periodontal evaluation (D0180) provided on June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0675), and a segmental 
gradient pressure pneumatic appliance (E0673), provided on April 5, 2021. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the items were medically 
necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by 
Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device 
(E0675), and a segmental gradient pressure pneumatic appliance (E0673), provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and the EKG provided on May 13, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit and the EKG. You say that you were never advised that the procedure would need authorization by insurance. The Plan denied your request. The Plan says no prior authorization was 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. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit and the EKG provided on May 13, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on June 3, 2020.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if the services are not available from preferred providers. You say that the in-network benefits should be honored, and the claim should be processed for payment. The Plan denied your request. The Plan says the code is not appropriate for the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on June 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you can't do anything on your own and it's not safe for you to be discharged. The Plan denied your request. The Plan says that the therapy you need can safely be received at a different setting.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet joint injection.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications.

The file shows that a lumbar facet injection was requested. We looked at the file and the rules. The medical records show that the enrollee experienced 50% pain relief for 3 months following the previous facet block. After the first diagnostic facet joint procedure, there must be a consistent positive response of at least 80% relief of primary pain. Based on this information, we find that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a facet joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four restorative procedures (D2999 x4).

You asked the Plan to pre-approve the restorative procedures. You say that you cannot afford to pay for these services. The Plan denied your request. The Plan says this service is not covered under your benefit package.

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 four restorative procedures (D2999 x4).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 10, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you feel that the charges are too high for the service you received. 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 $45 copayment for each visit with a specialist. You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the interventional cardiology visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the interventional cardiology visit. You say that your doctor recommended you see the out-of-network doctor. You say you need a specialist that will intervene and repair your heart condition. 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. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve an interventional cardiology visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bilateral buttock lipoaugmentation.
You asked the Plan to pre-approve a bilateral buttock lipoaugmentation. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. We looked at the file and Medicare rules. In this case, the requested procedure is not for repair of accidental injury or to improve the functioning of a malformed body member. There is no medical need for the requested procedure based on the documentation. Based on this information, we decided that Medicare rules for coverage of a bilateral buttock lipoaugmentation have not been met. Therefore, we decided that the Plan does not have to pre-approve a bilateral buttock lipoaugmentation