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

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first
intraoral periapical x-ray (D0220), two core buildups, including any pins when required (D2950 x2),
gingivectomy or gingivoplasty (D4212), pontic (D6240), and two retainer crowns (D6750 x2) provided on May
24, 2021.
You asked the Plan to pay for the dental services. You say that you contacted the Plan and dental office to
verify if the dentist was covered under your plan before you received these services. You also say that you
should be reimbursed for the $1,000.00 discrepancy. The Plan denied your request. The Plan says these
services are not covered. The Plan also says that during your calls with the Plan, you were provided with no
misinformation, and were mailed a copy of the Plan's covered code-specific dental benefits on May 17, 2021.
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
problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), two core buildups,
including any pins when required (D2950 x2), gingivectomy or gingivoplasty (D4212), pontic (D6240), and
two retainer crowns (D6750 x2) provided on May 24, 2021.
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 you would like reconsideration because the LTACH services are medically necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.
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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the denosumab injection rendered on February 26, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.

We looked at the file and Medicare rules. There is no documentation to support that the criteria for coverage of
the denosumab injection were met. 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 pay for the denosumab
injection rendered on February 26, 2021.

Local Coverage Determination (LCD) L34648 and Local Coverage Article (LCA) A52399 referenced by the
Plan are not valid for Part B Medicare and were not used in the Maximus determination.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on May 12, 2021.
You asked the Plan to pay for a CT scan. You say that the enrollee had multiple procedures. The Plan denied your request. The Plan says this is not separately payable.
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 70450 has a bundled relationship with code 70496 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 a computed tomography (CT) scan (70450) provided on May 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone-Acetaminophen for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Oxycodone-Acetaminophen for the enrollee.

Benefits for this 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 an Axumin positron emission tomography (PET) scan.

You asked the Plan to pre-approve the Axumin PET scan. You say that this imaging is needed to evaluate the
enrollee's treatment options. The Plan denied your request. The Plan says this is not covered for newly
diagnosed prostate cancer.

The Plan must follow Medicare rules. Medicare rules say that individual consideration is allowed for coverage
of PET imaging using radiopharmaceuticals for the FDA-approved indication.

We looked at the file and Medicare rules. The FDA indication for Axumin (fluciclovine F-18) states: "Axumin
is a radioactive diagnostic agent indicated for positron emission tomography (PET) imaging in men with
suspected prostate cancer recurrence based on elevated blood prostate specific antigen (PSA) levels following
prior treatment." In this case, there has been no prior treatment to this newly confirmed prostate cancer. As
such, the request is not for the FDA-approved indication for Axumin. Based on this information, we decided
that Medicare rules for coverage of the Axumin PET scan have not been met. Therefore, we decided that the
Plan does not have to pre-approve an Axumin positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on July 16, 2021.

You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says you did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The 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 out of network physician services provided on July 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira pen injections (J0135).

You asked the Plan to pre-approve the Humira pen injections. You say that Humira is helping the enrollee keep
the psoriasis under control. You also say that the enrollee has tried Enbrel in the past. The Plan denied your
request. The Plan says the Humira pen is on the self-administered drug list and is excluded from coverage
under Part B.

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 Humira pen injections
(J0135).

Benefits for the Humira pen injections 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the tumor immunohistochemistry rendered on May 26, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not billed with an appropriate diagnosis code.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis
code.
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate
diagnosis code. 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 pay for the tumor immunohistochemistry
rendered on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for special anesthesia service (99100) provided on March 23, 2021.

You asked the Plan to pay for anesthesia. You say that this service was medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 99100 is always bundled for payment and is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that code 99100 is always bundled for payment, and if it is covered the payment for it is subsumed by the patient for services to which it is incident. 

We looked at the file and Medicare rules. This code is always bundled for payment and is not separately payable. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for special anesthesia service (99100) provided on March 23, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 23, 2021.
You asked the Plan to pay for the laboratory services. You say that the gene panel plays an important role in
establishing mutations which will guide appropriate medical management of the patient. You say that the
information provided demonstrates the test as medically necessary and should be covered at the in-network
benefit level. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the laboratory services provided on February 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the duplex scans provided on April 7, 2021, and April 28, 2021.

You asked the Plan to reduce the copayments for the duplex scans. You say that you are requesting that the claims are processed as minor scans as opposed to a large-scale scan. The Plan denied your request. The Plan says you have been asked to pay 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 $105 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in an in-network physician's office or at an in-network free-standing facility (such as a radiology center or medical clinic). 

You have been asked to pay a $105 copayment for each of the duplex scans. The duplex scans fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows duplex scans are considered diagnostic radiological services. 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 reduce the copayments for the duplex scans provided on April 7, 2021, and April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered on January 8, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that only one hospital discharge day management service is
payable per patient per hospital stay.
We looked at the file and Medicare rules. The file shows that the Plan previously paid a discharge code for this
enrollee for this date of service. 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 pay for the hospital
discharge services rendered on January 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from July 21, 2020 to November 13, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claims were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with one of three required Q codes. 

We looked at the file and Medicare rules. The file shows that the home health claims were not billed with one of the three required Q codes. 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 pay for the home health services rendered from July 21, 2020 to November 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT.

You asked the Plan to pre-approve additional PT. You say that additional PT not medically necessary. The Plan
denied your request. The Plan says additional PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 additional PT. Our reviewer says that
skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition.
Our physician reviewer found the additional requested therapy is not generally accepted as specific and
effective therapy for your condition beyond what was approved by the health Plan. You have had prior
therapy and the records do not demonstrate that the unique skills of a professional therapist are required to
provide treatment safely and effectively, that the services can be safely and effectively performed only by a
therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program.
The requested services are not part of a maintenance program, are the specialized skill, knowledge and
judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current
condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional PT have not been met. Therefore, we decided that the Plan does not
have to pre-approve additional PT.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic testing provided on January 6, 2021.
You asked the Plan to pay for the testing services. You say that you were unable to find relief by relying on standard tests. The Plan denied your request. The Plan says you are responsible for the full cost of naturopathic services.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. We looked at the file and the rules. The services at issue in this appeal were referred by a naturopathic provider. Medicare does not cover naturopathic services. Consequently, the services ordered by a non-covered provider are likewise noncovered. The services were not authorized by the Plan. We found no exception which would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the diagnostic testing provided on January 6, 2021.
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 SNF services. You say that going home would be a serious risk to you. The Plan denied your request. The Plan says that your records show that you can safely be transferred to a different setting.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on April 9, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. We looked at the file and Medicare rules. Billed procedure code 99153 (moderate sedation services) has a PC/TC indicator of 3 and no professional component payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on April 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307, G0482) rendered by the out-of-network (OON) provider on December 30, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug testing (80307, G0482) rendered by the out-of-network (OON) provider on December 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on June 11, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that you 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 $250 copayment for CT scans. You have been asked to pay the allowed amount of $144.04, which is less than the $250 copayment for a CT scan. A CT scan falls 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 a CT scan provided on June 11, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the retroperitoneal ultrasound you had at an outpatient hospital facility on May 28, 2021.
You asked the Plan to reduce the copayment for the ultrasound. You say that you were told that the copayment was $40 for this service. 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 ($95.46) 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 $100 copayment for diagnostic tests in an outpatient hospital facility. You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the diagnostic
tests in an outpatient hospital facility 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 reduce the copayment for the retroperitoneal ultrasound you had at an outpatient hospital facility on May 28, 2021.