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

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on May 11, 2021.
You asked the Plan to waive the copayment for a specialist office visit. You say that you think that this should be covered with the mammogram. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for physician/practitioner services/in-network/specialist. You have been asked to pay a $45 copayment for a specialist office visit. The correct copayment has been applied to the services that were provided. A specialist office visit falls within the physician/practitioner services/in-network/specialist 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
office visit provided by a participating provider on May 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve these services. You say that SNF services are medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria for SNF services are not met. Maximus
overturned the Plans denial. The Plan requested a reopen and provided additional information.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for skilled nursing
facility (SNF) services after January 17, 2021. Maximus determined that the file did not show that a valid
notice of non-coverage as delivered two or more days before January 17, 2021. The Plan requested a reopen
and provided the necessary documentation. Based on the medical records provided, no required skilled nursing
services are identified. The documentation does not support that the enrollee required skilled nursing or skilled
therapy services daily in a skilled nursing facility on an inpatient basis after January 17, 2021. 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the transthoracic echocardiography (93306) and the x-ray exam of the chest (71046) provided on April 7, 2021 and April 28, 2021.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 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 $45 copayment per provider, per date of service for routine radiology (x-ray, radiology, diagnostic services, and ultrasounds).

You have been asked to pay $90 ($45 copayment x 2) for the radiology services provided. 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 transthoracic echocardiography (93306) and the x-ray exam of the chest (71046) provided on April 7, 2021 and April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam provided by an out-of-network provider on May 12, 2021.

You asked the Plan to pay for the eye exam. You say that the patient did not have any input in choosing who the optometrist would be and relied on the staff to ensure he received the exam. You say that the provider performing services in a nursing home is not responsible to obtain authorization and the doctor should be reimbursed for all services rendered. The Plan denied your request. The Plan says an authorization was not received for out-of-network services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the eye exam provided by an out-of-network provider on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the specimen handling services rendered on January 18, 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 procedure code 99000 is not separately payable.

The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Billed procedure code 99000 (handling and/or conveyance of specimen for transfer from the office to a laboratory) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the specimen handling services rendered on January 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing services provided on December 8, 2020.

You asked the Plan to waive the copayment for laboratory testing services. You say that you were at a wellness visit. You say wellness visits are covered at 100%. The Plan denied your request. The Plan says you have been charged 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 laboratory tests are not included with the Annual Wellness Visit. The contract with the Plan also clearly states you must pay a $10 copayment for laboratory tests. 

You have been asked to pay a $10 copayment for laboratory testing services. Laboratory testing services fall 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 diagnostic services provided on December 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a non-emergent ambulance transportation
service (A0428) provided on March 31, 2021.
You asked the Plan to waive the copayment for an ambulance transportation service. You say that you were
picked up from a hospital and taken to a rehabilitation center. You also say that the hospital called the
ambulance company for the transport and you do not think it is fair to have a copayment when you did not call
the ambulance. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $250
copayment for each one-way Medicare-covered ambulance services. Non-emergency transportation by
ambulance is appropriate if it is documented that the member's condition is such that other means of
transportation could endanger the person's health and that transportation by ambulance is medically required.
You have been asked to pay a $250 copayment for an ambulance transportation service. The EOC confirms
$250 is the required copayment for this service. 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 nonemergent
ambulance transportation service (A0428) provided on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a subsequent nursing facility care visit (99308) provided on February 16, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a nursing facility care visit. You say that you rendered treatment to the member in good faith and there was no adequate time frame to obtain authorization for this service. The Plan denied your request. The Plan says services should be received from network providers who are listed in the provider directory, except when urgent or an emergency.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 a subsequent nursing facility care visit (99308) provided on February 16, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the occlusal guard (D9945).

You asked the Plan to pre-approve the occlusal guard (D9945). You say that you have tried three or more hard mouth guards that didn't work and were very uncomfortable. The Plan denied your request. The Plan says the service is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the occlusal guard (D9945).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that these items are medically necessary for your condition. The Plan denied your request. The Plan says these items are not covered by Medicare.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346) and complete series of intraoral x-rays (D0210) provided on February 8, 2021, and March 2, 2021.

You asked the Plan to pay for the scaling and complete series of intraoral x-rays. You say that the provider assured you that the x-ray and cleaning would be covered in full. You also say that you never received a scaling. The Plan denied your request. The Plan says the scaling is not covered under your plan. The Plan also says that the complete series of intraoral x-rays does not meet the frequency requirements of the 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, scaling in presence of generalized moderate or severe gingival inflammation (D4346) is not among those covered under this benefit. The contract says that complete series of intraoral x-rays (D0210) is limited to one procedure every three plan years. The record shows that you received a complete series of intraoral x-rays (D0210) on November 10, 2020 and your complete series of intraoral x-rays (D0210) benefit has been exhausted. The Plan says that the provider of the first complete series of intraoral x-rays was different from the current provider, and your current provider would not have known that this procedure was already rendered. Therefore, we decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346) and complete series of intraoral x-rays (D0210) provided on February 8, 2021, and March 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone density study (77080) provided on May 27, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for a bone density study. You say that you would have obtained prior authorization had you known the rendering provider was out-of-network with the Plan. The Plan denied your request. The Plan says services should be received from network providers who are listed in the provider directory, except when urgent or an emergency.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 a bone density study (77080) provided on May 27, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six occlusal adjustments (D9951 x6).

You asked the Plan to pre-approve the occlusal adjustments. The Plan denied your request. The Plan says these services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve six occlusal adjustments (D9951 x6).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on April 7, 2021.

You asked the Plan to waive the copayment for emergency care. You say that your primary care physician told
you to go to the emergency room and they only gave you a drink to take and sent you home. 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 an $85
copayment for emergency care.

You have been asked to pay an $85 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 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left atrial appendage closure for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has permanent atrial fibrillation and requires anti-coagulation long-term given the elevated CHA2DS2VASc score. He has no history of bleeding or stroke, has been well maintained on warfarin and his HASBLED score is only 1. Based on the applicable CMS criteria for use of the device, he currently meets the elevated CHA2DS2VASc score criteria only. There is no documentation of shared decision making with a non-implanting cardiologist in the records provided and the evidence-based tool to assess bleeding risk (HASBLED=1) puts him at low risk for bleeding. He has no clear contraindications to long term anti-coagulation therapy as there are a number of alternatives to ibuprofen therapy for back pain and there is no documentation of any alternative therapies which have been used and failed. Based on this, the enrollee does not meet the full criteria for this request. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a left atrial appendage closure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued coverage of a bilevel positive airway pressure device (E0470).

You asked the Plan to pre-approve continued coverage of a bilevel positive airway pressure device. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for continued coverage of the positive airway pressure device have not been met.

The Plan must follow Medicare rules. Medicare rules say that for continued coverage of a positive airway pressure device, there must be objective adherence to therapy as detailed in the Medicare rules section. 

We looked at the file and Medicare rules. In this case, the medical records note that the enrollee's compliance of 4 hours per night with the PAP device was less than the required 70% of nights during a consecutive 30-day period. Based on this information, we decided that Medicare rules for coverage of continued coverage of a bilevel positive airway pressure device have not been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage of a bilevel positive airway pressure device (E0470).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit, x-ray and treatment to be provided by an
out-of-network provider.
You asked the Plan to pre-approve an office visit, knee x-ray and treatment with an out-of-network provider.
You say that the enrollee wants to stay with the provider as she has a relationship with him, and he was able to
find an alternative treatment. The Plan denied your request. The Plan says the enrollee can have an office visit,
x-ray and possible treatment with the in-network pain management specialist.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office
visit, x-ray and treatment to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the required services exceed the clinical capabilities of lower levels of care. The Plan denied your request. The Plan says the enrollee will not benefit from and improve with LTACH management.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a spinal cord injury. The enrollee was intubated/ventilated and subsequently received a tracheotomy. It is unclear that the enrollee is a candidate for full ventilator liberation or decannulation. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.