Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve use of pembrolizumab (Keytruda).  You asked the Plan to pre-approve Keytruda. You say that the enrollee meets criteria for use of Keytruda. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the enrollee does not meet the requirements for Keytruda.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Keytruda. Our reviewer says that the enrollee meets the criteria for the requested use of Keytruda. Our physician reviewer found the enrollee received combination therapy with platinum chemotherapy and will now get maintenance with Keytruda. Keytruda is Food & Drug Administration (FDA) approved for the enrollee's diagnosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve use of pembrolizumab (Keytruda).   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bone replacement grafts (D7953 x4).  You asked the Plan to pre-approve bone replacement grafts. You say that the service is medically necessary. The Plan denied your request. The Plan says the services at issue 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 pre-approve bone replacement grafts (D7953 x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) provided by a participating provider on May 12, 2021.  You asked the Plan to pay for the removal of residual tooth roots. You say that you were in a lot of pain. The Plan denied your request. The Plan says this benefit has already been exhausted.  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. The Plan covers supplemental dental services up to a maximum of $2000 per year. You exhausted this limit prior to these services being rendered.   We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the removal of residual tooth roots has already been exhausted. Therefore, we decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) provided by a participating provider on May 12, 2021.   Your quality-of-care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-emergency wheelchair van transport (A0130), and non-emergency transportation, per mile, (A0080) provided on June 24, 2021.    You asked the Plan to pay for the transportation service. You say that you required more extensive personal rehabilitation services after your surgery. You say that the medical staff arranged your transport to the skilled nursing facility. You also say that the transport was medically necessary. The Plan denied your request. The Plan says the transportation was not scheduled through the Plan's transportation vendor. The Plan also says that transportation services are not covered under your Point of Service benefit.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when trips must be scheduled through the Plan's transportation vendor.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the file shows that the transportation provider is out of network. Additionally, wheelchair van transportation is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the non-emergency wheelchair van transport (A0130), and non-emergency transportation, per mile, (A0080) provided on June 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 18, 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 if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code  is not supported in the medical record. Specifically [*****explain why code billed is not supported******]. 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 laboratory services provided to the enrollee on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the LAVAPPO (D9999) provided on April 27, 2021.  You asked the Plan to pay for the LAVAPPO. You say that you had extended dental coverage at the time you received these services. You also say that you feel that the services should be covered. The Plan denied your request. The Plan says LAVAPPO is not listed as a covered dental 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 LAVAPPO is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the LAVAPPO (D9999) provided on April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on May 27, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.    We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve knee joint replacement surgery to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve knee joint replacement surgery to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.  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 knee joint replacement surgery to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that denial of SNF care is detrimental to your ability to return home at the prior level of function. The Plan denied your request. The Plan says that the denial of SNF care is correct.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that you meet criteria for skilled nursing facility (SNF) care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. However, you do have daily skilled therapy needs. You have made some progress with physical therapy and have not yet been shown to have reached a plateau in function. You would benefit from additional strength, endurance, transfer, and wheelchair training. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of your condition. Your care needs - as a practical matter - cannot currently be provided at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.   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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on July 7, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a diagnostic laryngoscopy (31575) and hospital outpatient clinic visit (G0463) provided by a hospital outpatient facility on August 30, 2021.  You asked the Plan to waive the copayment for a laryngoscopy and outpatient hospital visit. You say that you have asthma and Chronic Obstructive Pulmonary Disease (COPD) and had been experiencing a frequent pinching sensation in your throat followed by coughing spells. You state this can be dangerous given your conditions. You also say that the doctor looked down your throat with a camera and prescribed medications to treat the symptoms.   You assert that the procedure was not surgery and had nothing to do with your larynx or chronic laryngitis. You say you believe this appeal was improperly denied. The Plan denied your request. The Plan says the claim was processed correctly in accordance with your benefits.  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 $325 copayment for Outpatient Surgery for Medicare-covered outpatient services at hospital facilities.   You have been asked to pay a $177.72 copayment for a laryngoscopy and outpatient hospital visit. A laryngoscopy is considered a surgical procedure and falls within the Outpatient Surgery benefit category due to the procedure being conducted in an outpatient hospital facility. The Plan only allowed the provider to bill for $306.09. The Plan paid $128.37, leaving a balance of $177.72.   $306.09 (Allowed) - $128.37 (Plan Paid) = $177.72 (Member Liability)  Since the charges are less than the required $325 copayment, you are only responsible for the lesser amount. 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 diagnostic laryngoscopy (31575) and hospital outpatient clinic visit (G0463) provided by a hospital outpatient facility on August 30, 2021.   Your complaint about a potential coding mistake 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (88108) provided on February 9, 2021.  You asked the Plan to pay for the laboratory service. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (88108) provided on February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for hearing aids provided on March 9, 2021.  You asked the Plan to pay for hearing aids. You say that when you called the Plan to inquire about hearing aid coverage, there was no mention about purchasing the hearing aids from the Plan provider. The Plan denied your request. The Plan says hearing aids must be ordered through the Plan's hearing aid provider.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered through the Plan's hearing aid provider.  We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered through the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on March 9, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy (90832) rendered by the out-of-network (OON) provider on August 3, 2021.  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 psychotherapy (90832) rendered by the out-of-network (OON) provider on  August 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device.  You asked the Plan to pre-approve the Superion device. The Plan denied your request. The Plan says this is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Superion device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex Superion device is experimental. More research is needed to show safety and efficacy of this 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 Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (0242U) provided on May 21, 2021.  You asked the Plan to pay for laboratory services. You say that this is a covered service. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (0242U) provided on May 21, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve a second opinion visit to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve second opinion. You say that you have seen 4 oncologists and feel that you have not received support from a team of physicians. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network specialist.  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 plans can require enrollees to get care from network providers.  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 submit a copy of the applicable Evidence of Coverage (EOC) for 2021. Without this, we cannot determine whether your contract with the Plan has a network lock-in rule that would require you to get care from only network providers. Although the Plan has shown that they have in-network providers who may be able to treat you, they have not shown that you are contractually obligated to receive care from an in-network provider. Therefore, the Plan has not shown that its decision to deny authorization for this service is correct or justified according to Medicare rules and your contract with the Plan. Therefore, we decided that the Plan has to pre-approve a second opinion visit to be provided by an out-of-network (OON) provider.   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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on August 11, 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 services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a nursing facility setting and should have been billed with POS code 32. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (19120) provided on March 22, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.  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 19120 is "Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions".  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services.  Our reviewer says that the use of code 19120 is not supported by the records provided. Our reviewer found that the operative report describes excision soft tissue, there is a more appropriate code to report for this service. Therefore, CPT 19120 cannot be confirmed.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (19120) provided on March 22, 2021.