Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory gene panel provided on January 4, 2021.

You asked the Plan to pay for the gene panel. You say that you provide timely testing services. The Plan denied your request. The Plan says the testing is not a Medicare benefit for the diagnoses listed on the claim.

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 at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the respiratory gene panel provided on January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a half-leg segmental gradient pressure pneumatic appliance and a pneumatic compression device provided on August 14, 2020.

You asked the Plan to pay for the gradient pressure pneumatic appliance and the pneumatic compression device. You say that the items in dispute were medically necessary. The Plan denied your request. The Plan says the enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included in the facility DRG or PPS prospective payment.

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 items at issue in this appeal were provided for use outside of the home. Although this item may have been helpful, neither Medicare nor the Plan covers equipment for use outside the home.

Therefore, we decided that the Plan does not have to pay for a half-leg segmental gradient pressure pneumatic appliance and a pneumatic compression device provided on August 14, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to waive the cost share amount for the prophylaxis and pay up to the maximum allowance for the filling. We decided that the Plan does not have to pay an additional amount beyond the maximum allowance for the filling.
You asked the Plan to waive the cost share amount for the dental services. You say that you received a bill for $20. The Plan denied your request. The Plan says the claim processed appropriately. The Plan says that there is a $150 allowance for supplemental dental services. The Plan also says that the allowance has been exceeded.
We decided that the Plan has to waive the cost share amount for the prophylaxis and pay up to the maximum allowance for the filling.
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.
Your contract with the Plan says that enrollees pay a $0 copayment for preventive dental services for preventive dental services and the $150 allowance only applies to supplemental dental services, including fillings and simple extractions. Based on the Plan contract, however, you cannot be asked to pay more than $0 copayment for preventive dental services. Therefore, we decided that the Plan has to waive the cost share amount of $39.
Additionally, the remaining allowance of $41 will be applied to the filling for tooth # 18. Therefore, we decided that the Plan has to pay up to the maximum allowance for the filling.
We also decided that the Plan does not have to pay an additional amount beyond the maximum allowance for the filling.
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 filling is listed as covered, the annual allowance for supplemental dental services has been exceeded. The record shows that the Plan paid $109 for the filling you received on February 4, 2021, leaving you with a remaining allowance of $41. The remaining $41 will be applied to the filling for tooth # 18. You are responsible for the remaining balance of $137. Therefore, we decided that the Plan does not have to pay an additional amount for the filling.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig (A9282).
You asked the Plan to pre-approve a wig. You say that the item is necessary. The Plan denied your request. The
Plan says based on the documentation provided, coverage criteria has not been met.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are
ordered by a physician. The Plan follows these same rules.
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As
such, it is non-covered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig (A9282).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle-foot orthoses (AFOs) rendered on April 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 medically necessary.
The Plan must follow Medicare rules. Medicare rules say that an AFO is covered when specific criteria are met.
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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee was evaluated on March 30, 2021 for concern about swelling of her ankles and feet. The exam showed "some edema to both lower extremities." There is no documented exam of the ankles or feet. There is no documentation that the enrollee requires stabilization for medical reasons and has the potential to benefit functionally. The AFOs were 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 pay for the ankle-foot orthoses (AFOs) rendered on April 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient surgery provided on February 18, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for outpatient surgery. You say that you were not given the correct insurance information from the enrollee. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 outpatient surgery provided on February 18, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on June 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on June 17, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist telehealth services provided by a participating provider on April 28, 2021.
You asked the Plan to waive the copayment for specialist telehealth services. You say that you only talked on the phone. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $40 copayment for physician/practitioner services/specialist. You have been asked to pay a $40 copayment for specialist telehealth services. When telehealth services are provided, a corresponding copayment is applied. Specialist telehealth services fall within the
physician/practitioner services/specialist 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 specialist telehealth services provided by a participating provider on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the gynecology visit you had on August 5, 2019.
You asked the Plan to waive the copayment for the gynecology visit. You say that you have never had a copayment before. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for visits with a specialist. 
You have been asked to pay a $35 copayment for the gynecology visit. The gynecology visit falls within the specialist visit 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 gynecology visit you had on August 5, 2019.
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 the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee is medically stable, and has no daily skilled nursing needs. There are no physical and occupational therapy needs noted in the documentation. This is not required in an inpatient setting. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 lumbar spinal stenosis. The requested Superion spacer is considered experimental in nature, as more research is needed to show safety and efficacy. The services are 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 a Vertiflex Superion spacer.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on April 13, 2021.
You asked the Plan to pay for lab test. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the clinical value and effectiveness for the enrollee's diagnosis have not been demonstrated.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for laboratory testing provided on April 13, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on May 20, 2021.

You asked the Plan to waive the copayment for an injection. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $275 copayment for outpatient surgery/outpatient hospital facilities. 

You have been asked to pay a $275 copayment for an injection. The injection that you received is considered an outpatient surgery; therefore, the correct copayment has been applied. The injection you received falls within the outpatient surgery/outpatient hospital facilities 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 an outpatient surgery provided by a participating provider on May 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the spine.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says this appeal is denied due to the enrollee no longer being eligible.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found there is no detailed neuromuscular exam in the records, and there is no mention of changes in symptoms or physical findings since the prior MRI in 2013. Absent any red flags such as absent or diminished reflexes, unexplained weakness etc. the medical necessity of repeat MRI of the lumbar spine has not been established in the provided records. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on April 29, 2021.

You asked the Plan to pay for the panoramic x-ray. You say that your regular doctor was not there, and many
x-rays were taken. You say that it was a strange visit and the charges are abnormal. The Plan denied your
request. The Plan says the service is not a covered benefit.

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
panoramic x-ray provided on April 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Alimta for the enrollee.
You asked the Plan to provide coverage for Alimta. You say that this drug 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 Alimta
(Pemetrexed). The Maximus Physician Reviewer determined that the requested drug is medically reasonable
and necessary. The Plan argues that there is no established evidence to support the use of Alimta (pemetrexed)
as subsequent therapy for metastatic vaginal cancer after multiple lines of prior chemotherapy. The records
show the enrollee is diagnosed with metastatic squamous cell carcinoma of the vagina. The enrollee has been
treated the prior chemotherapy regimens. The Plan is correct in this case. Alimta is not FDA-approved for the
treatment of metastatic squamous cell carcinoma of the vagina, and its use is not supported by the major drug
compendia, or by clinical research that appears in a CMS-approved medical journal. We looked at this
physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of Alimta have not been met. Therefore, we decided that the Plan does not have to provide coverage
for Alimta for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says experimental and investigational procedures are not covered by Medicare.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this device is experimental. More research is needed to show safety and efficacy of the device.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the sacroiliac (SI) joint radiofrequency ablation (64625).

You asked the Plan to pre-approve the sacroiliac (SI) joint radiofrequency ablation. You say that the service is
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that services that are not medically necessary are not
covered. The rules also say that experimental and investigational devices 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 sacroiliac (SI) joint radiofrequency
ablation. Our reviewer says that the requested service is not considered medically reasonable and necessary in
this case. Our physician reviewer found this is considered experimental/investigational due to the wide
variation in efficacy reported in the literature.

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 sacroiliac (SI) joint radiofrequency ablation have not been met. Therefore,
we decided that the Plan does not have to pre-approve the sacroiliac (SI) joint radiofrequency ablation (64625).