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

We decided that the Plan does not have to pay for the transportation of a portable x-ray (R0070) provided on June 23, 2021.
You asked the Plan to pay for the transportation of a portable x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not billed with the required set-up code.
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 R0070 is not supported in the medical record. Specifically, this claim was not billed with the required radiology codes. Based on this information, we decided that Medicare rules for coverage of the transportation of a portable x-ray have not been met.
Therefore, we decided that the Plan does not have to pay for the transportation of a portable x-ray (R0070)
provided on June 23, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for infectious agent and COVID-19 testing provided on July 6, 2021.
You asked the Plan to pay for infectious agent testing. You say that this testing is crucial and you find that the Plan's denial is in error. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing was non-covered screening.
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. 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 denied payment on the basis that this testing was non-covered screening in nature. However, the lab order submitted shows that this testing was requested for non-screening purposes. The Plan did not provide any other rationale or evidence to support this denial of payment. 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 infectious agent and COVID-19 testing provided on July 6, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services provided from November 7, 2020, to December 4, 2020.
You asked the Plan to waive the copayment for the skilled nursing facility services. You say that the services should be covered as the enrollee was falsely discharged. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided to the enrollee.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $100 copayment per day for days 21-100 of Skilled nursing facility (SNF) care.
The enrollee has been asked to pay a $100 copayment per day for seven days of skilled nursing facility services from November 28th, 2020, to December 4th, 2020 ($100 x 7 = $700). This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services provided from November 7, 2020, to December 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services of home health/hospice aide in home health or hospice settings, each 15 minutes (CPT code G0156).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says you do not meet the guidelines for the requested Home Health Aide services because you currently live with three other adult family members and you have not completed a recent in-person in-home assessment of needs which is needed to determine medical necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer found there is no documentation that the requested services meet the definition of home health aide services criteria. Records do not document any current skilled nursing or therapy needs or that you are currently receiving any skilled nursing or therapy services. There is no documentation that the requested home health
aide services meet Medicare criteria for reasonable and necessary to the treatment of your illness or injury by the skilled professional staff. Records do not document any current skilled nursing or therapy needs or that you are currently receiving any skilled nursing or therapy services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve services of home health/hospice aide in home health or hospice settings, each 15 minutes (CPT code G0156).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation/general anesthesia (D9222 and D9223).

You asked the Plan to pre-approve the deep sedation/general anesthesia services. The Plan denied your request. The Plan says these services are not covered under your benefit plan.

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 deep sedation/general anesthesia (D9222 and D9223).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Proair Respiclick for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Proair Respiclick for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the FreeStyle Libre therapeutic continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the monitor is denied because there are not at least three insulin injections per day.

The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 

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 monitor. Our reviewer says that the requested monitor is not medically reasonable or necessary. Our physician reviewer found the record does not indicate that the enrollee is on insulin three or times a day. The elements of the 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 the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the FreeStyle Libre therapeutic continuous glucose monitor.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (99601) provided from April 26, 2021, to May 3, 2021.
You asked the Plan to pay for home infusion therapy. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with a valid code.
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 99601 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this
information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (99601) provided from April 26, 2021, to May 3, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair out of network.
You asked the Plan to pre-approve a manual wheelchair from an out of network provider. You say that you prefer to use the requested provider. The Plan denied your request. The Plan says this provider is 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 pre-approve care from out-of-network providers only in certain circumstances. The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the item at issue in this appeal. We found no exception that would require the Plan to pre-approve a manual wheelchair out of network. Therefore, we decided that the Plan does not have to pre-approve the requested out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transport chair.
You asked the Plan to pre-approve a transport chair. You say that you cannot transport your wheelchair. The
Plan denied your request. The Plan says that a transport chair is not covered for use outside the home.
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 item at issue in this appeal 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. Therefore, we decided that the Plan does not
have to pre-approve a transport chair
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to wave the copayment for a specialist office visit and the onabotulinumtoxina injection provided on June 4, 2021.
You asked the Plan to wave the copayments for the specialist office visit and onabotulinumtoxina injection. You say that the services should be covered as these services used to be cheaper under your previous plan. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
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 $30 copayment for Physician/Practitioner services, including doctor's office visits, specifically specialist office visits and a 20% coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a $30 copayment for a specialist office visit and a 20% coinsurance for an onabotulinumtoxina injection (allowed amount for the injection is $3,817.80 x 20% = $763.56 + $30 = $793.56). Onabotulinumtoxina injections fall within the Medicare Part B prescription drugs 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 wave the copayment for a specialist office visit and an onabotulinumtoxina injection provided on June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 23.
You asked the Plan to pre-approve the dental service. You say that the crown is medically necessary. The Plan denied your request. The Plan says 1 crown is covered per tooth, per patient every 60 months. The Plan also says that the frequency limit has been reached.
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 crown is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a crown for tooth # 20 that you received on September 4, 2020. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 23.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to retroactively pay for these dental services.
You asked the Plan to pay for dental extractions. You say that you had dental deterioration due to radiation.
You say that you need heart surgery. You say that you needed your teeth removed before you could have the
heart surgery. You also say that you were under the impression the referral from your primary care provider
would take care of getting these services covered. The Plan denied your request. The Plan says the services you
received are dental in nature. The Plan also says extractions are not a covered service after radiation has been
provided for disease. The Plan only covers extractions prior to radiation.
This case was forwarded to Maximus for review by the Plan. Based on the Medicare non coverage rules for
dental services and the Plan contracts supplemental benefits for dental services, Maximus upheld the Plans
decision.
You requested an ALJ hearing. The ALJ sent a request for information to Maximus requesting medical records.
Maximus responded to the ALJ in an email indicating medical records were not required to review this case as
this was a contract issue and not a medical necessity issue. The ALJ remanded the decision back to Maximus
stating they had not received a response and that medical records should have been requested.
Maximus reviewed the case on reopen and is standing on its decision without medical records as they are not
required for review. Medicare covers extractions under the medical benefit to treat injury of the jaw due to
trauma or for preparation of the jaw prior to radiation for disease or for services provided by a doctor to correct
facial issues. It is understood that deteriorating teeth can cause problems for enrollees who require surgery for
fear of spread of infection. In this case extractions would have been covered prior to you receiving radiation
treatment. However, the deterioration to your teeth was caused by radiation and the extractions occurred after
the radiation, which is not covered by the Plan. These were extractions provided after radiation by a dental
professional, not a physician. The fact that a physician may have recommended this dental work in preparation
for heart surgery is not of issue. The argument is not that the concern for infection was not valid, but that
extractions provided by a dentist and billed under dental codes after radiation are not covered by Medicare or
the Plan. Therefore, it remains our decision that the Plan does not have to pay for the surgical extractions
(D7210) provided from June 17, 2020, to July 6, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consult and three extractions to be provided by an oral surgeon.
You asked the Plan to pre-approve the consult and extractions. You say that you were referred to an oral surgeon by your dental provider. The Plan denied your request. The Plan says your contract only provides coverage for dental services when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon are not covered.
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 rendered by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a consult and three extractions to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a filling (D2332) for tooth # 9.
You asked the Plan to pre-approve the dental service. You say that you switched dental offices. You also say that you understand that x-rays needed to be performed to determine the extent of damage to your tooth that was broken in half. The Plan denied your request. The Plan says a filling is not 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, the requested filling is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a filling (D2332) for tooth # 9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the caries risk assessment.
You asked the Plan to pre-approve the caries risk assessment. 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 pre-approve the caries risk assessment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met in a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an initial 15 minutes of deep sedation (D9222) and each additional 15 minutes of deep sedation (D9223 x 3).
You asked the Plan to pre-approve the dental services. You say that you have a severe infection in your mouth. You say that your dentist advised not removing your tooth could result in damage to adjacent teeth. You say that you are anxious and apprehensive about getting your tooth pulled. The Plan denied your request. The Plan says deep sedation services are not listed as covered services.
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 deep sedation services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an initial 15 minutes of deep sedation (D9222) and each additional 15 minutes of deep sedation (D9223 x 3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular implant/abutment supported removable denture for edentulous arch (D6111), semi-precision abutments (D6191), semi-precision attachments (D6192), and implant procedures (D6199)
You asked the Plan to pre-approve the mandibular implant/abutment supported removable denture, semi-precision abutments, semi-precision attachments, and implant procedures. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services are not covered under your benefit plan.
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 a mandibular implant/abutment supported removable denture for edentulous arch (D6111), semi-precision abutments (D6191), semi-precision attachments (D6192), and implant procedures (D6199)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar orthosis (L0641).
You asked the Plan to pre-approve a lumbar orthosis. You say that you have the right to a new back brace whenever you need it. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the reasonable useful lifetime of equipment in no case can be less than 5 years. Computation of the useful lifetime is based on when the equipment is delivered to the enrollee, not the age of the equipment. We looked at the file and Medicare rules. In this case, you are requesting a replacement for a lumbar orthosis provided on March 4, 2021. Therefore, the requested replacement is for an item that has not outlasted its reasonable useful lifetime. Based on this information, we decided that Medicare rules for coverage of a lumbar orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar orthosis (L0641).