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

We decided that the Plan does not have to pre-approve the bone graft (D6104).
You asked the Plan to pre-approve the bone graft (D6104). 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 bone graft (D6104).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Calciprotriene cream.
You asked the Plan to pre-approve self-administered drug. You say that the enrollee has had a diagnosis of psoriasis since 2017 and needs this medication. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 Calciprotriene cream.
Benefits for self-administered 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary interim partial denture (D5820).
You asked the Plan to pre-approve the maxillary interim partial denture. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service is not covered under your benefit 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 pre-approve a maxillary interim partial denture (D5820).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory pathogen testing provided on August 21, 2020.
You asked the Plan to pay for the respiratory pathogen testing. You say that this should be paid. The Plan denied your request. The Plan says the COVID-19 testing was reimbursed; however, the billing issue prevents payment for the remaining line items.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the respiratory pathogen testing have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory pathogen testing provided on August 21, 2020.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary.

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 reviewer says 
that the requested admission to a LTACH is not medically necessary. Our physician reviewer found there is no 
documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving 
appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are 
not available at the acute care hospital where he is currently receiving care. There are no services available at 
the LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee.

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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-covered item (A9270), Aqua guard shower sheets.
You asked the Plan to pre-approve the Aqua guard shower sheets. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Aqua guard shower sheets have not been met. Therefore, we decided that the Plan does not have to pre-approve the non-covered item (A9270), Aqua guard shower sheets.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15 units of intensive outpatient group psychotherapy
(90853).
You asked the Plan to pre-approve the outpatient psychotherapy. You say that please reconsider and approve
the units that you have requested. You also ask for consideration of future units as you move forward with her
in the program. The Plan denied your request. The Plan says the enrollee does not meet medical necessity for
continued outpatient therapy groups.
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 outpatient psychotherapy. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found based on review the records provided, it is noted that this enrollee is not
showing any suicidal ideation has various stresses including housing instability where she is being evicted from
her apartment. The enrollee's medications include Paxil, Seroquel and Klonopin for which she has shown
improved function. The enrollee has been able to take care of her own needs without assistance where she is
been able to leave home and go to public places. This enrollee has been able to be around males and has been
able to share trauma history with her family. Based on the information provided, this enrollee's documentation
does not show severity of symptoms requiring additional group psychotherapy sessions as the enrollee is been
able to participate in various activities and care for herself therefore making additional group therapy visits as
no longer being necessary and reasonable.
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 outpatient psychotherapy have not been met. Therefore, we decided that the
Plan does not have to pre-approve 15 units of intensive outpatient group psychotherapy (90853).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 12, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that you saw a physician's assistant not a specialist and disagree with the charges. 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 $40 copayment for specialist visits. 

The record shows that you received services from a specialist on August 12, 2021. Therefore, you are responsible to pay the $40 copayment. 

You have been asked to pay a $40 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 August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ophthalmology office visit (99204) to be provided by an out-of-network provider.

You asked the Plan to pre-approve the office visit. You say that the services are medically necessary. The Plan denied your request. The Plan says there are network providers available. The services are not emergent in nature.

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 ophthalmology office visit (99204) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have waive either of these copayments.
You asked the Plan to waive these copayments. You say that you do not believe this cost share is correct. The
Plan denied your request. The Plan says this cost share was charged based on the services provided and the
Plan contract agreement. Maximus partially overturned the Plans denial for insufficient information regarding
the urgent care visit. The Plan requested a reopen and provided the required documentation.,
The Plan is correct in this case. 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 $65 copayment for each urgent care visit. 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 charged for the urgent care visit provided on November 12, 2020 and the office visit
provided on November 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transportation services provided
on February 19, 2020.
You asked the Plan to waive the copay for the services provided. You say that this was a return to the rehab
facility for continued skilled care. The Plan denied your request. The Plan says the claim processed correctly
per the enrollee's benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $200 copay for ground travel for ambulance services.
The enrollee has been asked to pay a $200 copay for the services provided. The services fall within the
ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the
ambulance transportation services provided on February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) urine pregnancy test (81025) provided on January 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you understand you are not in network. You are asking for a special review of records to consider payment at an in network benefit for visits made from 01/01/2020 to 06/30/2020. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99214) urine pregnancy test (81025) provided on January 9, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on April 7, 2021.
You asked the Plan to pay for the definitive drug testing. You say that this should be paid. The Plan denied your request. The Plan says the POS code reported is not supported.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the
lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the definitive drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical implant placement (D6010) and implant supported removable denture (D6111).

You asked the Plan to pre-approve the surgical implant placement (D6010) and implant supported removable denture (D6111). The Plan denied your request. The Plan says the services are not covered 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 the surgical implant placement (D6010) and implant supported removable denture (D6111).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on November 4, 2020
and billed under code G0463.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the records do not support the services billed. Maximus overturned the Plans denial. The
Plan requested a reopen and provided additional information. The Plan provided documentation showing only
11 drug classes had been tested and not 22. Therefore, code G0463 is not the appropriate code for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code. In this case, the number of drug classes billed does
not support the number of drug classes tested or performed. Medicare rules for coverage of these services have
not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee
on November 4, 2020 and billed under code G0463
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve budesonide capsules.
You asked the Plan to pre-approve self-administered drug. You say that this medication has worked for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 budesonide capsules.
Benefits for self-administered 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the lower back/lumbar spine.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no physician order for this request.
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 MRI is not medically reasonable or necessary. Our physician reviewer found there is no clinical
documentation submitted to support the medical necessity of this request. There is no documentation of the
enrollee's history of injury/illness, subjective complaints, objective clinical findings, x-ray findings, prior
conservative treatment, or current diagnosis. Therefore, this request for MRI of the lower back/lumbar spine is
not medically reasonable and necessary at this time.
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 not been met. Therefore, we decided that the Plan does not have
to pre-approve MRI of the lower back/lumbar spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a re-cement or re-bond crown (D2920) to be rendered by an out-of-network (OON) provider.
You asked the Plan to pre-approve the re-cement or re-bond crown. You say that you are getting recurrent infections due to the hole in your tooth. You also say that you do not know when you will be able to travel back home to see your regular dentist. The Plan denied your request. The Plan says the provider requested is not in-network with the Plan. The Plan also says that there are in-network providers available to render the requested service.
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 OON. Therefore, we decided that the Plan does not have to pre-approve a re-cement or re-bond crown (D2920) to be rendered by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR, HHS). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from
August 6, 2020, through August 9, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service 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). The enrollee's contract with the Plan clearly says that he must pay
$325 per day, for days 1-5 for in-network inpatient hospital care.
The enrollee has been asked to pay $975 ($325 x 3 days) for the inpatient hospital care provided. This means
that the enrollee has been asked to pay the correct amount based on his contract with the Plan. This cost sharing
is a contractual obligation the enrollee agreed to pay when he enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for the inpatient hospital care provided from August 6, 2020,
through August 9, 2020.