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

We decided that the Plan does not have to pre-approve unspecified fixed prosthodontic procedure, tooth #11 (CPT code D6999).
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve unspecified fixed prosthodontic procedure, tooth #11 (CPT code D6999).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. You say that Keytruda 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 Keytruda
(Pembrolizumab). The Maximus Physician Reviewer determined that first-line, single-agent treatment with
Pembrolizumab is indicated for non-small cell lung cancer in enrollees with stage III NSCLC (who are not
candidates for surgical resection or definitive chemoradiation) or in enrollees with metastatic NSCLC, and with
tumors with PD-L1 expression (tumor proportion score [TPS] greater than or equal to 1%), as determined by an
approved test, and with no epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK)
genomic tumor aberrations. The records show 2 sites of disease in the right upper and right lower lobe.
The Plan argues that the enrollee did not have unresectable disease and did not have disease in 2 lobes as stated
in the Maximus review.
The medical records show the enrollee has a diagnosis of stage IIIB N2M0 non-small cell lung cancer. A
PET/CT demonstrated a mass in the superior segment of the right lower lobe and the upper anterior right lower
lobe, as well as uptake in the right hilum suspicious for metastatic involvement. The enrollee underwent
resection of the right lower lobe, and mediastinal node dissection. Pathology revealed two separate
malignancies, a poorly differentiated adenosquamous carcinoma and a poorly differentiated adenocarcinoma.
Metastatic poorly differentiated carcinoma was present in 9 out of 20 nodes. The Plan is correct in this case.
The documentation does not support that the enrollee had disease in two lobes of the lung.
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 not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda for the enrollee
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on April 15, 2021.
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that a social worker endorsed this transport via stretcher, who in fact deemed it medically necessary and the safest and most suitable mode for transport from the nursing home to the doctor's office. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office or facility for a scheduled appointment is not a Medicare covered benefit.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance service, basic life support,
non-emergency transport. Our reviewer says that the ambulance transport was not medically reasonable and necessary. Our physician reviewer found based on the medical records provided there is no documentation that
a stretcher van was contraindicated for this enrollee. There is no documentation that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. There is no documentation that the ambulance transport on April 15, 2021 was medically reasonable and necessary for the enrollee as records do not clearly document that a stretcher van was contraindicated for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on April 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 24, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there are no medical records from the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. The records provided also do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional accessories (L5999) for a lower extremity prosthesis.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says L5999 cannot be used for a request for a cover.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. The use of code L5999 is not allowed in this case. Based on this information, we decided that Medicare rules for coverage of the accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional accessories (L5999) for a lower extremity prosthesis
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy, premolar tooth (excluding final restoration), tooth #29 (CPT code D3320).
You asked the Plan to pre-approve the dental services. You say that the root canal on tooth #29 was approved but the nerve treatment was not approved. You state there is no way to have a root canal done without this treatment. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy, premolar tooth (excluding final restoration), tooth #29 (CPT code D3320).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit (CPT code 99214) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the office visit. You say that this provider has several decades of experience in the type of reconstructive surgery that is needed to correct your facial paralysis. The Plan denied your request. The Plan says there is an in-network provider that provide the consultation.
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 the office visit (CPT code 99214) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve reline complete maxillary denture (indirect), tooth number(s): 1 and 16 (CPT code D5750) to be provided by an out-of-network provider.

You asked the Plan to pre-approve the dental services. You say that you were given incorrect information by the customer service. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve reline complete maxillary denture (indirect), tooth number(s): 1 and 16 (CPT code D5750) to be provided by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure coded 95999, the electroencephalogram (EEG) coded 95955, the nerve conduction studies coded 95907, and the needle electromyography services coded 95886 provided on July 3, 2020.
You asked the Plan to pay for the unlisted neurological or neuromuscular diagnostic procedure, the electroencephalogram (EEG), the nerve conduction studies, and the needle electromyography services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 95999, 95955, 95907 and 95886 are not supported in the medical record. Specifically, the technical report did not include documentation of an unlisted neurological or neuromuscular diagnostic procedure; therefore, code 95999 cannot be verified. The technical report did not include documentation of electroencephalogram (EEG) during nonintracranial surgery (carotid surgery); therefore, code 95955 cannot be verified. The technical report did not include documentation of nerve conduction studies, for 1-2 studies; therefore, code 95907 cannot be verified. The technical report did not include documentation of a complete needle electromyography, per each extremity with related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity study; for five or more muscles studied, innervated by three or more nerves or four or more spinal levels (listed separately in addition to code for primary procedure); therefore, code 95886 cannot be verified.
Based on this information, we decided that Medicare rules for coverage of the unlisted neurological or neuromuscular diagnostic procedure, the electroencephalogram (EEG), the nerve conduction studies, and the needle electromyography services have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure coded 95999, the electroencephalogram (EEG) coded 95955, the nerve conduction studies coded 95907, and the needle electromyography services coded 95886 provided on July 3, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97110) provided on February 8,
2021.
You asked the Plan to pay for physical therapy services. You say that these services were not available innetwork.
The Plan denied your request. The Plan says these services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that when therapy services are billed as incident to a
physician/non-physician practitioner (NPP) services, the requirement for direct supervision by the
physician/NPP and other incident to requirements must be met, even though the service is provided by a
licensed therapist who may perform the services unsupervised in other settings.
We looked at the file and Medicare rules. The services at issue were billed by a nurse practitioner, but the
records do not show that the nurse practitioner was present and providing direct supervision. Based on this
information, we decided that Medicare rules for coverage of physical therapy services have not been met.
Therefore, we decided that the Plan does not have to pay for physical therapy services (97110) provided on
February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on October 20, 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 to you by an out-of-network provider on October 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup, including any pins (CPT code D2950), for the enrollee.
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve core buildup, including any pins (CPT code D2950), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on April 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab tests. You say that you have had your primary care provider for years, were told it was fine, and cannot afford to pay for this out-of-pocket. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.
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 laboratory testing provided on April 22, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Hemoglobin; glycosylated (A1C) (CPT code 83036) and Vitamin D; 25 hydroxy, includes fraction(s) (CPT code 82306) provided to the enrollee on December 16, 2020, by an out-of-network provider.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says this screening testing is not authorized because predictive screening testing is not a Medicare benefit.
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, the laboratory services, 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 Hemoglobin; glycosylated (A1C) (CPT code 83036) and Vitamin D; 25 hydroxy, includes fraction(s) (CPT code 82306) provided to the enrollee on December 16, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult incontinence garments, for the enrollee.
You asked the Plan to pre-approve adult incontinence garments. You say that the enrollee has urinary incontinence and needs the diapers to use whenever the enrollee has an appointment or needs to leave the house to run errands. The Plan denied your request. The Plan says the items requested are not covered by Medicare. The Plan states adult incontinence garments are included in the enrollee's OTC monthly benefit monthly benefit and enrollees have the option of four diaper sizes, small, medium, large and extra-large. The Plan states the enrollee has not placed their August 2021 OTC order; however, their July 2021 order included incontinence underwear.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve adult incontinence garments, for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve brain imaging, PET; metabolic evaluation (CPT code
78608), for the enrollee.
You asked the Plan to pre-approve the PET scan. You say that the enrollee has demonstrated impulsivity and
determination to self-transfer, which is not advised though the enrollee is unable to remember to ask for help,
and the self-transfers result in falls. You state the enrollee has had multiple falls that have not resulted in severe
injury. You state if there is testing that could lead to determining the cause of the enrollee's balance issues that
could result in interventions that could improve this for them. The Plan denied your request. The Plan says the
service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 PET scan. Our physician reviewer
found the review has determined that the medical records shows that the enrollee had a diagnosis of dementia
in 2019 and had not yet been evaluated for specific alternate neurodegenerative diseases. Medicare policy
requires documentation of the recipient recently receiving a diagnosis of dementia and documented cognitive
decline of at least six months, who meets the diagnostic criteria for both Alzheimer's disease (AD) and
Frontotemporal Dementia (FTD). Medicare also requires documentation that the recipient has been evaluated
for specific alternate neurodegenerative diseases or other causative factors, but cause of clinical symptoms
remains uncertain; and the comprehensive clinical evaluation, conducted by a physician experienced in
diagnosis and assessment of dementia, indicating that the PET scan is reasonably expected to help clarify the
diagnosis between FTD and AD to guide with future treatment. The review has determined that the medical
records provided do not meet the requirements listed in the NCD for Medicare coverage.
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 PET scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve brain imaging, PET; metabolic evaluation (CPT code 78608), for the enrollee.
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 LTACH Admission is medically
necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current
level of care.
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 documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
required medical services identified that are available at the LTACH, that are not available at the current health
care setting being offered by the health plan.
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