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

We decided that the Plan does not have to pay for alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7311) provided April 23, 2021.

You asked the Plan to pay for the alveoplasty. You say that you received approval for the services performed on this date and you do not understand why they were not covered. The Plan denied your request. The Plan says the claims on this date of service have been reprocessed, however the alveoplasty is not covered under your benefits and your signed treatment plan shows that you would be fully responsible for the charges for this service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7311) provided April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on April 1, 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 claim was billed with the incorrect place of service.
The Plan must follow Medicare rules. The rules say that inpatient services must be billed with POS code 21. We looked at the file and Medicare rules. The file shows that billed procedure code 99222 (initial hospital care) was not billed with the required 21 POS 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 initial hospital care rendered on April 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for cosmetic surgery provided on April 26, 2021.

You asked the Plan to reimburse you for the cosmetic surgery. You say that the surgery was done to accomplish symmetry. The Plan denied your request. The Plan says the services are not covered as they are cosmetic services in nature.

The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 

We looked at the file and Medicare rules. The surgeon stated the surgery was done to correct a deformity and make both breasts similar in size. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not have to reimburse you for cosmetic surgery provided on April 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) (C8908, A9575) provided on January 11, 2021.

You asked the Plan to pay for an MRI. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with a correct principal diagnosis.

The Plan must follow Medicare rules. Medicare rules say that Z80.3 is an unacceptable principal diagnosis. 

We looked at the file and Medicare rules. The services at issue were billed with a primary diagnosis of Z80.3. Based on this information, we decided that Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) (C8908, A9575) provided on January 11, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on April 21, 2021.

You asked the Plan to waive the copayment for a colonoscopy. You say that the initial procedure was incomplete and you had no control over the equipment used nor the doctor's expertise. 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 

You have been asked to pay a $350 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 colonoscopy provided on April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test (G0480) provided on April 1, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a drug test. You say that you are a specialized laboratory that performs drug monitoring in good faith and at the request of the ordering physician who sends the authorizing requisition form. 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a drug test (G0480) provided on April 1, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on March 24, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also 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 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 physician services provided on March 24, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0673) provided on December 27, 2020.
You asked the Plan to pay for an intermittent limb compression device. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for the provided diagnosis.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers. The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device (E0673) provided on December 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies for a continuous glucose monitor (K0553) provided on January 3, 2021.
You asked the Plan to pay for supplies for a continuous glucose monitor. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery or relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for supplies for a continuous glucose monitor (K0553) provided on January 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network general surgeon.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is no gap issue and there are in-network providers available.

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 a referral to an out-of-network general surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a ventilator.
You asked the Plan to provide coverage for a ventilator. You say that a ventilator 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 coverage for a
ventilator (E0466). The Maximus Physician Reviewer determined that the documentation supported coverage
for the requested device. The Plan requested a reopen stating your needs can be met with a BiPap machine and
the requested device is being used in the bilevel PAP mode rather than being used as a home ventilator.
The Plan is correct in this case. The controlling rules state that ventilators may be covered when they are
medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic
respiratory failure due to chronic obstructive pulmonary disease (COPD). The rules also say that the decision
to use a ventilator or a bi-level positive airway pressure device is made based upon the specifics of each
person's medical condition. There must be enough detailed information in the medical record to justify the
treatment selected.
The medical records show that you have been prescribed ventilator prescription with AVAPS settings. The
ordering pulmonologist has not provided a detailed statement why the BiPAP machine with AVAPS settings is
not appropriate for you. The elements of the controlling coverage criteria 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 a ventilator have not been met. Therefore, we decided that the Plan does not
have to provide coverage for a ventilator
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, crown, core buildup, including any pins when required, and endodontic therapy provided on May 15, 2021 by an OON provider.

You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, crown, core buildup, and endodontic therapy. You say that this visit was an emergency, your dentist was not open, and you were in extreme pain. You also say that you checked online, and it showed this treating provider accepted your insurance which you thought meant the provider was in-network. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that dental services need to be provided in-network to be eligible for payment.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, crown, core buildup, including any pins when required, and endodontic therapy provided on May 15, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.
You asked the Plan to pre-approve the requested services. You say that the ablation procedure would be less invasive. The Plan denied your request. The Plan says nerve ablation is only appropriate if a nerve block as shown temporary relief of pain.
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 requested services. Our physician reviewer found that you have right groin and medial thigh/testicular pain which developed after inguinal hernia repair with mesh. The mesh was removed in a subsequent procedure, but the pain persists. You had 2 ilioinguinal nerve blocks without effect. RFA of the ilioinguinal nerve is not indicated when prior diagnostic nerve blocks did not relieve the pain. Therefore, the request 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality test (D0460) provided on February 23, 2021.
You asked the Plan to pay for the dental service. You say that you were not able to chew on the right side of your mouth without pain. You say that you were also experiencing sensitivity to cold. You say that your dentist referred you to an endodontist. You also say that you feel the service should be covered. The Plan denied your request. The Plan says pulp vitality test 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, pulp vitality test is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pulp vitality test (D0460) provided on February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 5, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the drug testing services provided on June 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hearing services provided on May 20, 2021.

You asked the Plan to waive the copayment for hearing services. You say that you would have refused the test if you had known that you would owe an additional copayment. 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 $35 copayment for hearing services. 

You have been asked to pay a $35 copayment for hearing services. Hearing services fall within the hearing services 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 hearing services provided on May 20, 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 the LTACH care is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to a LTACH.
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 that the enrollee appears to be unstable and with worsening infiltrates, and only requires additional short-term acute care services to stabilize which can be safely administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary as transfer at this time would not provide a significant clinical advantage.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for evoked potential studies (95939, 95938) provided on November 11, 2020.
You asked the Plan to pay for evoked potential studies. You say that this was medically necessary. The Plan denied your request. The Plan says the billed diagnosis does not support that this was necessary.
The Plan must follow Medicare rules. Medicare rules say that limited diagnosis codes support medical necessity and provide coverage for procedure codes 95925, 95926, 95927, 95928, 95929, 95938, and 95939. Diagnosis I71.4 is not listed as supporting medical necessity. We looked at the file and Medicare rules. The services at issue were billed with diagnosis code I71.4, which does not support medical necessity. Based on this information, we decided that Medicare rules for coverage of evoked potential studies have not been met. Therefore, we decided that the Plan does not have to pay for evoked potential studies (95939, 95938) provided on November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1832) provided on February 23, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the orthosis. You say that you were not aware that you were out of network or that authorization was required. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan 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 knee orthosis (L1832) provided on February 23, 2021 by an out-of-network (OON) provider.