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

We decided that the Plan does not have to pay for the excision of a benign lesion (D7411) provided on June 14, 2021.
You asked the Plan to pay for the excision of a benign lesion. You say that you are on social security and cannot afford the charge for this service. 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 excision of a benign lesion (D7411) provided on June 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) (A9276).
You asked the Plan to pre-approve the CGM. You say that the item is medically necessary. The Plan denied your request. The Plan says you do not self-adjust your insulin dosage based on the blood glucose testing results.
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 require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) (A9276).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the
enrollee beyond May 13, 2021.
You asked the Plan to pre-approve continued skilled nursing facility services. You say that continued SNF
admission was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria
were not met at the time of the request.
Maximus overturned the Plans denial due to the lack of documentation of proper notice in the case file. The
Plan requested a reopen and provided a copy of the notice served to the enrollee or representative stating
coverage would end on May 13, 2021.
We reviewed the case file and the reopen request. 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. The medical records show that as of May 13, 2021, the enrollees care was custodial in
nature. The records show the enrollee refused to participate in therapy and refused medication. The records
show the enrollee had reached a plateau and at that point all assistance was custodial in nature for daily
activities such as dressing, bathing and toileting. The records do not show that the enrollee required daily
skilled nursing or daily skilled therapy services at that point. Therefore, we decided that the Plan does not have
to pre-approve continued skilled nursing facility (SNF) services for the enrollee beyond May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 15,
2021.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your
request. The Plan says this test is not included in any professional society management or treatment guidelines.
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 pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the requested testing to predict clinical events or alter the treatment of individuals is considered to be
investigational.
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 pay for laboratory services provided to the enrollee on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950)
and first intraoral periapical x-ray (D0220) provided on May 17, 2021.
You asked the Plan to pay for the core buildup and first intraoral periapical x-ray. You say that prior to
receiving these services the dentist showed you that everything would be covered in full by the Plan. You also
say that you were later advised the core buildup was no longer covered, and you were never notified until you
received the bill. The Plan denied your request. The Plan says core buildup is not a covered service. The Plan
also says that your benefits for the first intraoral periapical x-ray have been satisfied and the frequency
limitation has been exceeded.
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, core buildup, including any pins when
required (D2950) is not among those covered under this benefit. The contract says that intraoral x-rays are
limited to one procedure code per calendar year. The record shows that you received a first intraoral periapical
x-ray (D0220) on January 21, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, we decided
that the Plan does not have to pay for the core buildup, including any pins when required (D2950) and first
intraoral periapical x-ray (D0220) provided on May 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network physical therapy.
You asked the Plan to pre-approve out-of-network physical therapy. The Plan denied your request. The Plan
says in-network providers are available, and the Plan could also provide transportation to the in-network
providers.
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. Therefore, we decided that the Plan does not have to pre-approve
out-of-network physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation to be provided by an OON
provider.
You asked the Plan to pre-approve an office consultation. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services can be provided by a network
provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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. Therefore, we decided that the Plan does not have to pre-approve
an office consultation to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the 30 minutes of additional critical care services (99292) provided on January 20, 2021.
You asked the Plan to pay for the 30 minutes of additional critical care services. You say that the medical records support the services as billed. The Plan denied your request. The Plan says the total documented critical care time does not support payment of this code.
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 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). We find that CPT code 99292 is not supported in the medical record. Specifically, the documentation supports that 40 minutes of critical care time were provided to the enrollee. This is covered under the Plan's coverage of CPT code 99291. There is no support for an additional 30 minutes of critical care services beyond what the Plan has already agreed to cover. Based on this information, we decided that Medicare rules for coverage of the 30 minutes of additional critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the 30 minutes of additional critical care services (99292) provided on January 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on February 11, 2020.
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says new
documents were submitted for this appeal and consist of progress notes for various dates other than the billed
date of service. Duplicates of records previously reviewed were also submitted.
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 services have not been met. Specifically, the physical therapy services were
provided by a PTA and billed as services incident to a NPP. Therefore, we decided that the Plan does not have
to pay for physical therapy services provided on February 11, 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 the SNF services. You say that SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee's care could be provided at an alternative level.

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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee had uncomplicated wound care to his sternal and coccyx wound. The enrollee completed a course of IV antibiotics. The enrollee received physical therapy and occupational therapy. He was at a supervision/touch assist level with functional mobility, including gait to 150 feet. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 

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 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: SNF
Decision: Unfavorable

We decided that the Plan has to hold the enrollee harmless for the skilled nursing facility (SNF) services provided from January 1, 2021, through February 15, 2021.
You asked the Plan to hold the enrollee harmless for the SNF stay. You say that you do not understand why you are being billed $5959.44 for the 18 days between January 28, 2021, and February 15, 2021. You feel this should be covered as the enrollee has Covid-19 during these dates. The Plan denied your request. The Plan says that the correct cost sharing has been applied.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan failed to submit a complete case file with documentation that related to the issues brought up in your appeal statement. The enrollee appears to have been a patient at the SNF in question from at least December 29, 2020. However, no enrollee liability was applied during the time in December 2020. The file included an Explanation of Benefits which indicates that the enrollee was responsible for $1958 for SNF services provided in January 2021. Maximus requested clarification from the Plan regarding this number because it does not correspond with any number of whole-day copayments based on the contract. Furthermore, your appeal statement clearly was in regard to a bill you received from the facility for dates January 28, 2021, through February 15, 2021. The Plan failed to address this amount or these dates. The file did not contain any evidence of what days of this SNF stay were covered nor when coverage was discontinued. Based on the specific services being appealed and the lack of pertinent documentation regarding these services, we are not able to verify what the correct cost sharing would be for the services provided during this span of dates. It is the Plan's responsibility to support that the amount being assigned to cost sharing, and any denied amounts were correctly calculated, and it has not done so in this case, despite Maximus sending a request for additional information. The Plan's processing of the claims as documented in the file is not supported. Therefore, we decided that the Plan has to hold the enrollee harmless for the skilled nursing facility (SNF) services provided from January 1, 2021, through February 15, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F2 and F5 testing.
You asked the Plan to pre-approve F2 and F5 testing. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested services are 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 F2 and F5 testing. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found you have the lupus anticoagulant. The clinical utility of testing for FVL or
prothrombin variants has not been demonstrated. Although the presence of inherited thrombophilia increases
the risk for subsequent VTE events, the increase is modest, and the absolute risk of thrombosis remains low.
Therefore, you do not meet criteria for the requested services.
Review of the file shows that the Plan uses Local Coverage Determination (LCD) L36155 to support their
denial. However, this LCD is not valid for your state. This means we are unable to use LCD L36155 to
substantiate our decision.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of F2 and F5 testing have not been met. Therefore, we decided that the Plan does
not have to pre-approve F2 and F5 testing.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services you received from May 2, 2021, to May 31, 2021.
You asked the Plan to waive the copayment for the SNF services. You say that you should not have the pay the copayments after day 20 because you could not participate in therapy due to your upcoming surgery. 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 $0 copayment for days 1-20, and a $184 copayment per day for days 21-100 for skilled nursing facility services.
Records show that were in the SNF for a total of 29 days between May 2, 2021, and May 31, 2021. You were not charged a copayment for the first 20 days of this stay. For the remaining days, you were charged a copayment of $184 (for a total $1656.) However, at the time the claim for these services was processed, you only had $1,011.96 remaining on your out-of-pocket maximum, so that is the amount you have been charged. The SNF copayments apply regardless of your ability to participate in therapy during your stay. 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 skilled nursing facility (SNF) services you received from May 2, 2021, to May 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis and caries risk assessment provided on April 16, 2021.

You asked the Plan to pay for the periodic oral evaluation, prophylaxis and caries risk assessment. You say that you were not informed about any changes in their Medicare acceptance status. You say that the service was paid in full without that knowledge and you are requesting a one-time reimbursement. The Plan denied your request. The Plan says payment cannot be issued for services from a provider that has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the
periodic oral evaluation, prophylaxis and caries risk assessment provided on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic services provided on June 22, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the diagnostic services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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. 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 diagnostic services provided on June 22, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lumigan solution.
You asked the Plan to pre-approve Lumigan solution. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
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 Lumigan solution.
Benefits for Lumigan solution 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 waive the copayment for the electrocardiogram (EKG) you had on
March 4, 2021.

You asked the Plan to waive the copayment for the EKG. You say that this service was covered in full
previously. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan
says that because the allowed amount for this service ($14.80) is less than your copayment obligation, you are
responsible for the full allowed 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 $35
copayment for EKGs.

You have been asked to pay a $35 copayment for the EKG. 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 electrocardiogram (EKG) you had on March 4, 2021.