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

We decided that the Plan does not have to pay for the interim caries arresting medicament applications (D1354) provided on March 18, 2021.
You asked the Plan to pay for the interim caries arresting medicament applications. You say that you would like this service to be reconsidered for coverage now and for the future. The Plan denied your request. The Plan says this service is 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 pay for the interim caries arresting medicament applications (D1354) provided on March 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998-RR) provided on April 18, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that the service was necessary. The Plan denied your request. The Plan says ambulance services are not covered when there is no transport.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 18, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998-RR) provided on April 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Percepta Bronchial Genomic Classifier testing provided 
on May 10, 2021. 
 
You asked the Plan to pay for the Percepta Bronchial Genomic Classifier testing. You say that the Percepta 
Bronchial Genomic Classifier testing provided on May 10, 2021 was medically necessary. The Plan denied 
your request. The Plan says the Percepta Bronchial Genomic Classifier testing provided on May 10, 2021 was 
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 pay for the Percepta Bronchial Genomic Classifier 
testing. Our reviewer says that the Percepta Bronchial Genomic Classifier testing provided on May 10, 2021 
was not medically necessary. Our physician reviewer found the enrollee is with emphysema, and a pulmonary 
nodule. The enrollee agreed to proceed with bronchoscopy and biopsy. Percepta Genomic Sequencing 
Classifier testing assesses the risk of lung cancer to guide next steps for patients being evaluated for potentially 
cancerous lung nodules and is to be used when biopsy results are inconclusive. As the results of biopsy were 
not yet available, the testing was not medically reasonable and 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 Percepta Bronchial Genomic Classifier testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Percepta Bronchial Genomic Classifier testing 
provided on May 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are an 82-year-old male post cervical spine surgery for spinal stenosis, currently in an inpatient rehabilitation facility. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric scooter (K0806).

You asked the Plan to pre-approve an electric scooter. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve an electric scooter (K0806).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the cost share for the office visit and injection services provided on April 16, 2021.

You asked the Plan to waive the cost share for the services provided. The Plan denied your request. The Plan says that the provider needs to bill Medicaid for the deductible amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.

The Plan says you must pay a deductible for the services provided. Based on the Plan contract, however, you do not have a deductible. Therefore, we decided that the Plan has to waive the cost share for the office visit and injection services provided on April 16, 2021.

Please note that our decision is only about your Medicare benefits. Maximus does not have jurisdiction with regard to Medicaid benefits. Please contact the Plan to find out how to file an appeal of the denial of Medicaid benefits.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve the dental item. You say that the night guard prevents you from damaging 
your teeth from Bruxism. You say that this should be a preventive service because it prevents you from 
damaging your teeth. You say that you had to pay for one out of pocket in the past when you did not have 
dental insurance. You also say that you should not have to pay out of pocket now because you do have dental 
insurance. The Plan denied your request. The Plan says occlusal guard is not listed as a covered 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 occlusal guard is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal guard (D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block.
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has knee pain and had a right knee genicular nerve block with 70 percent improvement in symptoms on the day of the injection. Genicular nerve blocks and genicular radiofrequency ablation are considered experimental/investigational in nature. The repeat block is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve the physical therapy. The Plan denied your request. The Plan says these medically necessary services are available in the service area with participating 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 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 physical therapy to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on April 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the anesthesia services. You say that at the time of service, the enrollee was unaware that prior authorization was required. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the anesthesia services provided on April 30, 2021 by an out-of-network
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve apolipoprotein E (APOE) genotype testing.

You asked the Plan to pre-approve apolipoprotein E (APOE) genotype testing. You say that the requested
apolipoprotein E (APOE) genotype testing is medically necessary. The Plan denied your request. The Plan says
the requested apolipoprotein E (APOE) genotype testing 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 apolipoprotein E (APOE) genotype
testing. Our reviewer says that the requested apolipoprotein E (APOE) genotype testing is not medically
necessary. Our physician reviewer found the requested service is of indeterminate clinical utility. A diagnosis
of Alzheimer's Dementia (AD) is commonly and customarily made on the basis of clinical evaluation and in
some cases with neurocognitive testing. While genetic testing is available, such testing is not required. APOE
genotyping in specific is not required for a diagnosis of AD. Nor is this specific type of genetic testing been
shown to assist in making a diagnosis of AD or assisting in long term patient's management or outcomes. Its
use is more suited for the academic/research environment. As such at this time the requested testing would be
best classified as being investigational and therefore would not be 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 apolipoprotein E (APOE) genotype testing have not been met. Therefore, we
decided that the Plan does not have to pre-approve apolipoprotein E (APOE) genotype testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive exam provided on March 23, 2021.
You asked the Plan to pay for the services provided. You say that the previous visit was diagnostic. The Plan denied your request. The Plan says the claim processed 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). We looked at the file and the rules. You received a preventive exam on March 23, 2021. You previously received a preventive exam on March 17, 2020. Your plan only covers this type of exam once every 24 months. Based on this information, we decided the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the preventive exam provided on March 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable x-ray provided on April 13, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the portable x-ray. You say that you are contracted by the enrollee's primary care doctor to provide x-ray services. The Plan denied your request. The Plan says the provider is out-of-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the portable x-ray provided on April 13, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 365-day supply of Yupelri 175 mcg/3 mL solution
(J7677).
You asked the Plan to pre-approve a 365-day supply of Yupelri 175 mcg/3 mL solution. You say that you
would like the Plan to reconsider your request. The Plan denied your request. The Plan says the drug is being
requested under medically accepted standards and the Plan has approved up to a recurring 90-day supply of this
drug, through December 31, 2021. The Plan says a supply greater than 90 days is not covered under Medicare.
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. The file shows that the drug is being requested under medically
accepted standards and the Plan has approved up to a recurring 90-day supply of this drug, through December
31, 2021. Medicare rules say a supply greater than 90 days is not covered. Therefore, we decided that the Plan
does not have to pre-approve a 365-day supply of Yupelri 175 mcg/3 mL solution (J7677).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is insufficient evidence of efficacy for the requested procedure.
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 this procedure is experimental. More research is needed to show safety and efficacy. 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 the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration (20939).

You asked the Plan to pre-approve bone marrow aspiration. You say that this request is medically necessary.
The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature.

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 bone marrow aspiration. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that this 61-year-old female was being treated for spinal stenosis. The lumbar fusion
procedure has been approved. However, there is limited published, large-scale, long-term peer-reviewed
literature that shows the request for bone marrow aspiration to be an effective and/or safe treatment for the
noted pathology. There is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for bone marrow aspirate (20939) with the approved L2-3 posterior decompression and instrumented fusion extension 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 bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for interrogation device evaluations provided from February 3, 2021, to May 7, 2021.

You asked the Plan to waive the copayments for interrogation device evaluations. You say that you did not authorize the evaluations and cannot get an explanation for 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 $0 copayment for diagnostic procedures and tests provided by a primary care physician and a $75 copayment when provided by any other physician.

The medical records show that you received an interrogation device evaluation on February 3, 2021. Therefore, you are responsible to pay the allowed amount of $65.30, which is less than the $75 copayment. 

The medical records show that you received an interrogation device evaluation on March 6, 2021. Therefore, you are responsible to pay the $75 copayment. 

The medical records show that you received an interrogation device evaluation on April 6, 2021. Therefore, you are responsible to pay the allowed amount of $65.30, which is less than the $75 copayment. 

The medical records show that you received an interrogation device evaluation on May 7, 2021. Therefore, you are responsible to pay the allowed amount of $65.30, which is less than the $75 copayment.

The total amount you owe is: $270.90. 

You have been asked to pay the total copayment amount of $270.90 for interrogation device evaluations. Interrogation device evaluations 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 copayments for interrogation device evaluations provided from February 3, 2021, to May 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on March 26, 2021.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says screening genetic testing is not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The testing services were requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on March 26, 2021.