Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says you do not have skilled nursing or therapy services that need to be provided on a daily basis as an inpatient.
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 physician reviewer found that you were at a standby assist level for chair mobility, contact guard assist for standing, minimal assist for walking and transfers, and contact guard assist for grooming. You do not have documented skilled nursing or skilled therapy needs. You are walking household distances. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (procedure code 99291) provided to the enrollee on April 1, 2021 and April 2, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes." We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not include notation of the spent providing the services. This information is needed, as CPT 99291 is a time-based 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 critical care services (procedure code 99291) provided to the enrollee on April 1, 2021 and April 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit and ophthalmoscopy provided on January 15, 2020.  You asked the Plan to waive the copayment for the office visit and ophthalmoscopy. You say that it has been over a year and a half and you never got a bill for anything for that appointment. You say that you paid your $45 copayment and you do not believe you should have to pay another $25. The Plan denied your request. The Plan says the copayments applied 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 $45 copayment for each Medicare-covered specialist office visit and a $25 copayment for other Medicare-covered outpatient diagnostic procedures and tests.   You have been asked to pay a $45 copayment for the office visit and a $25 copayment for the ophthalmoscopy. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The ophthalmoscopy 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 the office visit and ophthalmoscopy provided on January 15, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient behavioral health office visit provided on July 21, 2021 to July 29, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visits. You say that you sought out a different provider because you did not feel that the other doctor was helping you with your problem. You found the provider on a website, and it stated that they were in network. 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 outpatient behavioral health office visit provided on July 21, 2021 to July 29, 2021 by an out-of-network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion pump refill kit provided on June 17, 2021.
You asked the Plan to pay for the infusion pump refill kit. You say that the attached records support the medical necessity and the need for the billed units. You say that the records should be reviewed, and payment should be issued. The Plan denied your request. The Plan says the denial for code J3010 was overturned and the denial will be upheld for code A4220 as no separate payment is made for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code A4220 is refill kit for implantable infusion pump.
We find that CPT code A4220 is not supported in the medical record. Specifically, CPT code A4220 has a status indicator of P. This means that CPT code A4220 is considered a bundled/excluded code and is not separately payable. Based on this information, we decided that Medicare rules for coverage of the infusion pump refill kit have not been met. Therefore, we decided that the Plan does not have to pay for the infusion pump refill kit provided on June 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Imfinzi.  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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of castration-resistant metastatic prostate cancer and cholangiocarcinoma. The Food and Drug Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The Imfinzi is not safe and effective or reasonable and 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 Imfinzi.   Local Coverage Determination (LCD) L37205 referenced by the Plan contains the same criteria for coverage as the Medicare Benefit Policy Manual and was not used in the MAXIMUS determination due to this,
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Keytruda.  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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has heavily-pretreated ovarian cancer. PDL1+ status is not basis for approval of Keytruda. The enrollee does not have microsatellite instability or a total number of mutations of greater than 10. Keytruda is therefore 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 Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the autograft for spine surgery only (includes harvesting the graft) (20936) provided April 16, 2021.  You asked the Plan to pay for the surgical procedure. You say that both the primary surgeon and the facility are in network. The CPT codes billed are payable to the assistant surgeon and you would like for the assistant surgeon's claim to be processed at the in-network rate. The Plan denied your request. The Plan says the allowance for this service is already included in the approved procedure 22551.  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 the surgical procedure is a column II code to column I code 22551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the autograft for spine surgery only (includes harvesting the graft) (20936) provided April 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 10, 2021.  You asked the Plan to pay for the limited oral evaluation. You say that the evaluation was necessary to determine if you needed to have teeth extracted and to have lesions evaluated. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit 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 and the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on April 20, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intraoral x-rays (D0220, D0230) and panoramic x-ray (D0330) provided on June 22, 2021.  You asked the Plan to pay for the intraoral x-rays (D0220, D0230) and panoramic x-ray (D0330). You say that you went to the dentist because your tooth broke off at the gum line. You say that you were told he couldn't pull the tooth, but you were still sent a bill for $192. The Plan denied your request. The Plan says the services are not covered benefits.    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 intraoral x-rays (D0220, D0230) and panoramic x-ray (D0330) provided on June 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services provided on July 13, 2021.
You asked the Plan to pay for the surgical pathology services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 88305 is Level IV - Surgical pathology, gross and microscopic examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy - without uterus Lip, biopsy/wedge resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum,
biopsy Ovary with or without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp, cervical/endometrial Polyp, colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse Vagina, biopsy Vulva/labia, biopsy. We find that CPT code 88305 is not supported in the medical record. Specifically, the provider used a Clinical Laboratory Improvement Amendment Number (CLIA) that is not valid. This means this code is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the surgical pathology services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical pathology services provided on July 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a three-wheeled scooter.
You asked the Plan to pre-approve the requested services. You say that you need a scooter with compartments for groceries. The Plan denied your request. The Plan says you have already received a power scooter that meets your needs.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a scooter for home use. Your current scooter serves the same purpose as the requested scooter. The requested scooter 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.
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a three-wheeled scooter.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous passive motion (CPM) exercise device, for use other than knee (E0936) provided April 23, 2021 to June 26, 2021.
You asked the Plan to pay for the CPM device. You say that you feel you should not have to pay this bill amount. The intermittent limb compression device was ordered from your doctor. You did not ask for this device. You feel this should be covered by the Plan. The Plan denied your request. The Plan says based on Medicare guidelines, you do not meet the criteria as the records show that you had shoulder surgery.
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pay for the continuous passive motion (CPM) exercise device, for use other than knee (E0936) provided April 23, 2021 to June 26, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2781, V2799, V2025) purchased on June 8, 2021.
You asked the Plan to pay for the eyeglasses. You say that you purchased a previous pair of glasses, but they were stolen. You asked what your benefit limit was, and you were told you had a $200 benefit limit for glasses. Your first pair was less than this amount, and you feel you should receive some reimbursement for your second pair. The Plan denied your request. The Plan says you may only use your routine vision benefit once per year. You previously purchased a pair of eyeglasses in February 2021. Any remaining benefit dollars do not roll over to a future purchase. Therefore, the second pair of glasses you purchased in June 2021 exceeded the frequency limitations of your routine vision benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to a $200 benefit allowance toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses. Limit one per year. This benefit can only be used one time; any remaining benefit dollars do not "roll over" to a future purchase. We looked at the file and the Plan's rules. You previously purchased eyeglasses in February 2021. This means you have already used your routine vision benefit for the year. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2781, V2799, V2025) purchased on June 8, 2021.
Your complaint about potential incomplete information provided by a Plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: 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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria
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 enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. 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 the astigmatism correcting function of intraocular lens
(V2787) provided on May 18, 2021.
You asked the Plan to pay for the astigmatism correcting function of intraocular lens. You say that you would
like reconsideration because this lens was recommended by your physician and will prevent future
complications. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a
conventional IOL.
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatismcorrecting
feature of an IOL. Therefore, we decided that the Plan does not have to pay for the astigmatism
correcting function of intraocular lens (V2787) provided on May 18, 2021