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

We decided that the Plan does not have to waive the copayment for the telehealth visit you had with a neurologist on April 15, 2021.
You asked the Plan to waive the copayment for the telehealth visit. You say that you did not authorize this telephone call. You say that your doctor called you and the discussion was only 30 seconds long. The Plan denied your request. The Plan says you were charged this copayment 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 copayment for specialist visits, including telehealth services. You have been asked to pay a $40 copayment for the telehealth visit. The telehealth visit falls within the specialist visits benefit category. This copayment applies regardless of how long the telehealth visit lasts. 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 the telehealth visit you had with a neurologist on April 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (27695) provided December 27, 2020.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says payment for this CPT code is included in payment for another service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 27695 has a bundled relationship with code 27822 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (27695) provided December 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
You asked the Plan to pre-approve a Freestyle Libre. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for continuous glucose monitors have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scans provided from May 21, 2020, to May 29, 2020.

You asked the Plan to waive the copayment for the CT scans. You say that that you called customer service and were told there was no copayment for these services. 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 you must pay a $150 copayment for each Medicare-covered radiological diagnostic service, such as a CT scan. 

You have been asked to pay a $150 copayment for each CT scan. You had two CT scans, for a total of $300 (2 scans x $150 per scan = $300). CT scans 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 the CT scans provided from May 21, 2020, to May 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have provided coverage for additional routine transportation trips.

You asked the Plan provided coverage for additional transportation trips. The Plan denied your request. The Plan says you have exhausted your 2021 benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 40 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have provided coverage for additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair with padded arms.
You asked the Plan to pre-approve a shower chair. You say that a shower chair with padded arms is medically necessary. The Plan denied your request. The Plan says shower chairs 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 chair with padded arms.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig (A9282).

You asked the Plan to pre-approve a wig. You say that the requested cranial prosthesis is not for vanity's sake and is important and necessary. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. 

In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig (A9282).

Your complaint about receiving erroneous or incomplete information about your durable medical equipment benefit from representatives of the Plan 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the occupational therapy evaluation (97167) provided on March 30, 2021.

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). Your contract with the Plan clearly says that you must pay a $35 copayment for each in-network Medicare-covered occupational therapy service. 

You have been asked to pay a $35 copayment for the in-network Medicare-covered occupational therapy evaluation 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 copayment for the occupational therapy evaluation (97167) provided on March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment - includes placement (D6057), abutment supported porcelain/ceramic crown (D6058), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the endosteal implant, abutment, abutment supported crown and tooth extraction. You say that you would like the services covered. The Plan denied your request. The Plan says these services are not covered when provided out-of-network.

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. The Plan covers the endosteal implant, abutment, abutment supported crown and tooth extraction when the services are provided by a network provider.

We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the endosteal implant, abutment, abutment supported crown and tooth extraction have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment - includes placement (D6057), abutment supported porcelain/ceramic crown (D6058), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the implantation of an Optimizer Smart pulse generator (0408T).

You asked the Plan to pre-approve the implantation of an Optimizer Smart pulse generator. You say that this is medically necessary. The Plan denied your request. The Plan says that this is experimental for the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 implantation of an Optimizer Smart pulse generator. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found cardiac contractility modulation therapy with the Optimizer Smart Pulse device is a relatively newer technology which is approved by the Food and Drug Administration (FDA). You are already on maximal guideline directed medical therapy and remain significantly symptomatic. You have persistent moderately severe Class III symptoms and have also failed previous device implantation with no other reasonable clinical alternatives. Based on published data, expert opinion, as well the approved FDA indications for the device, the requested device implantation is medically 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 implantation of an Optimizer Smart pulse generator have been met. Therefore, we decided that the Plan has to pre-approve the implantation of an Optimizer Smart pulse generator (0408T).

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this service is considered experimental and investigational.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you can no longer stand in the shower and
need to be able to sit. The Plan denied your request. The Plan says this item is 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 chair
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Udenyca for the enrollee.
You asked the Plan to pre-approve Udenyca. You say that Udenyca is 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 stated that Maximus did not apply the correct criteria. Our Medical Director
looked at the case file and the reopen request. At issue is coverage for Udenyca (Pegfilgrastim-cbqv). The
Maximus Physician Reviewer determined the use of Udencya in this case is reasonable and medically
necessary to prevent neutropenic fever. On reopen the Plan argues there are no recommendations for the use of
growth factor/G-CSF support in patients being treated with cisplatin/pemetrexed. The records show the
enrollee has a diagnosis of stage IIIB lung adenocarcinoma. Treatment with cisplatin and pemetrexed was
started on April 30, 2021. The enrollee had chemotherapy-induced neutropenia. Our Medical Director has
concluded that the Plan is correct in this case. The enrollee is not on a chemotherapy regimen with a high or
intermediate risk for febrile neutropenia. As the enrollee did not experience febrile neutropenia and did not
have a dose-limiting neutropenic event, Udenyca would not be considered medically reasonable and necessary
in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of Udenyca have not been met. Therefore, we decided that the Plan
does not have to pre-approve Udenyca for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (root canal) (D3330) provided on March 26, 2021, by an out-of-network provider.

You asked the Plan to pay for the root canal. You say that you did not realize that either your Plan or your provider's status had changed, and you could no longer receive covered services from them. You feel the Plan should cover these costs because you were not informed prior to services. The Plan denied your request. The Plan says out-of-network dental care is not covered by your supplemental 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, items or services received from out-of-network dental providers are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the endodontic therapy (root canal) (D3330) provided on March 26, 2021, by an out-of-network provider.

Your complaint about a potential change in your Plan or possible misinformation 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99213) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an office visit. You say that the member has been experiencing headaches for a year and she would like to see a provider who specializes in headaches. 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 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. The records provided for review do not show that the services at issue are urgent or emergent. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit (99213) to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.

You asked the Plan to provide coverage for additional routine transportation trips. You say that driving a motor vehicle causes you more anxiety. The Plan denied your request. The Plan says you have exhausted the routine transportation benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) transmitter.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the criteria for coverage are not met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with insulin at least three times per day. 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 a Dexcom G6 continuous glucose monitor (CGM) transmitter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cryosurgical ablation of the prostate.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says you have not had radiation therapy.
The Plan must follow Medicare rules. Medicare rules say thatcryosurgery as salvage is only covered after the failure of a trial of radiation therapy, under the conditions noted 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 the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, you have not received radiation therapy. The review has determined that the requested is not medically reasonable or 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve cryosurgical ablation of the prostate.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided January 8, 2021.
You asked the Plan to pay for the critical care services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is a critical care visit of 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not document how much time was spent on this service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided January 8, 2021.