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

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 10, 2019.
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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on July 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the member meets criteria for admission and would like to participate in rehabilitation to regain function. The Plan denied your request. The Plan says the member does not need an intensive rehabilitation program, does not have complex medical management needs and does not require supervision by a rehabilitation physician.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Additionally, a less intensive, longer duration of therapy may be more appropriate. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 9, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 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 physician's services provided on September 9, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy with removal of tumors, polyps, or other lesions (45385) provided on September 24, 2019.
You asked the Plan to waive the copayment for a colonoscopy with removal of tumors, polyps, or other lesions. You say that you were told a colonoscopy would be rewarded The Plan denied your request. The Plan says this processed correctly as a diagnostic colonoscopy.
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 $150 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. It also says that a screening colonoscopy can become a diagnostic colonoscopy when the screening colonoscopy results in the biopsy or removal of a lesion or growth and the outpatient surgery copayment will apply. You have been asked to pay a $150 copayment for a colonoscopy with removal of tumors, polyps, or other lesions. A colonoscopy with removal of tumors, polyps, or other lesions falls within the outpatient surgery 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 a colonoscopy with removal of tumors, polyps, or other lesions (45385) provided on September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a leg surgery procedure (27599) provided on September 30, 2019.
You asked the Plan to pay for the leg surgery procedure. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the billed procedure does not appear on Addendum AA for covered surgical procedures under the ambulatory surgical center payment system. Additionally, the billed procedure does appear on Addendum EE for surgical procedures which are excluded from Medicare payment in ambulatory surgical centers.
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 27599 is not supported in the record. Specifically, 27599 is not listed on Addendum AA for covered surgical procedures under the ambulatory surgical center payment system. 27599 is listed on Addendum EE for surgical procedures which are excluded from Medicare payment in ambulatory surgical centers. Based on this information, we decided that Medicare rules for coverage of the leg surgery procedure have not been met. Therefore, we decided that the Plan does not have to pay for a leg surgery procedure (27599) provided on September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided  from August 9, 2019 to October 28, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 9, 2019 to October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hot/cold pack therapy (97010) and therapeutic exercises (97110) provided on August 15, 2019.
You asked the Plan to pay for the hot/cold pack therapy and therapeutic exercises. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested services are non-covered benefits under Medicare and the member's Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for hot/cold pack therapy (97010) and therapeutic exercises (97110) provided on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel injections (Sureclick)
You asked the Plan to pre-approve Enbrel injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 Enbrel injections (Sureclick).
Benefits for Enbrel injections may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the epidurography services coded 72275 provided on July 15, 2019.

You asked the Plan to pay for the epidurography 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.

In this case, the CPT Code Manual definition of code 72275 is Epidurography, radiological supervision and interpretation.

We asked our coder 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 the epidurography services. Our reviewer says that the documentation does not support the billing of code 72275. Our coder reviewer found according to CPT guidelines, imaging documentation and a formal report are services included in CPT code 72275. The medical records submitted do not contain evidence of the imaging or formal report for an epidurogram. Therefore, the billing of 72275 remains unsupported.

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 epidurography services have not been met. Therefore, we decided that the Plan does not have to pay for the epidurography services coded 72275 provided on July 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee roller purchased on June 11, 2019 from an out of network provider.
You asked the Plan to pay for the knee roller. You say that you are appealing the denial because you had surgery and was totally non-weight bearing. The knee roller was your only option for any type of mobility during that time. The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.
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 rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. 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. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the knee roller purchased on June 11, 2019 from an out of network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit provided on March 15, 2019.
You asked the Plan to pay for the office visit. You say that this should be covered. The Plan denied your
request. The Plan says that this was an out of network visit provided without authorization.
The Plan must follow Medicare rules. Medicare rules say that plans must submit a complete case file including
a copy of the appeal letter.
The file as received has no copy of the appeal. As such, we are not able to review the enrollee's argument to
verify if there is a valid exception to the network restriction rules. MAXIMUS sent a request for this
documentation on January 21, 2020 and did not receive a response. This request was a courtesy as plans are
expected to submit a complete file. Without a complete case file, we find that that denial is not substantiated.
Therefore, we decided that the Plan has to pay for the office visit provided on March 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost share for the outpatient hospital services you received on May 10, 2019, and May 29, 2019.
You asked the Plan to adjust the cost share. The Plan denied your request. The Plan says you are responsible for the cost share.
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 20% coinsurance for out-of-network outpatient hospital services. Review of the file shows that you were provided outpatient hospital services on May 10, 2019, and May 29, 2019. The services were allowed at a total of $3,248.01. You have been asked to pay a 20% coinsurance for the services, totaling $649.61. The services fall within the outpatient hospital services 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 adjust the cost share for the outpatient hospital services you received on May 10, 2019, and May 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecfidera for the enrollee.
You asked the Plan to pre-approve Tecfidera. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 Tecfidera.
Benefits for Tecfidera may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 3, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee has previously received the same supplies within the 5-year RUL.
The Health Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same durable medical equipment on January 27, 2017. This orthosis is still within the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the orthosis at issue. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the protective restoration (code D2940) provided on June 26, 2019.
You asked the Plan to pay for the protective restoration. You say that your doctor recommended this procedure. You also say that this service was not for cosmetic purposes. The Plan denied your request. The Plan says you Plan does not cover this procedure.
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 protective restoration (code D2940) provided on June 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0260).
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the enrollee 's current bed is too
high and the enrollee has to jump into the bed which causes him pain because he has two catheters. The Plan
denied your request. The Plan says the enrollee does not meet the medically necessary criteria.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered
medically necessary when the patient:
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or
2. Requires attachments which can only be attached to a hospital bed; AND
3. Requires frequent changes in body position and/or has an immediate need for a change in body position.
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 semi-electric hospital bed. Our
reviewer says that A semi-electric hospital bed is not medically necessary for this enrollee. Our physician
reviewer found the enrollee's condition does not require positioning of the body in ways not feasible in an
ordinary bed. The enrollee does not require frequent or immediate changes in body position. The enrollee's
condition does not require special attachments that cannot be fixed and used on an ordinary bed.
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 semi-electric hospital bed have not been met. Therefore, we decided that the
Plan does not have to pre-approve the semi-electric hospital bed (E0260).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 26, 2019 by an out of network provider.
You asked the Plan to pay for the podiatry services (99334 and 11721). You say that you would like reconsideration as there is an authorization on file for all care at the facility. The Plan denied your request. The Plan says non-urgent services should be from network providers who are contracted with the Plan and listed in the Provider Directory.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on August 26, 2019 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 17, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthotic(s) management and training services coded 97760 provided on June 20, 2019.
You asked the Plan to pay for the orthotic(s) management and training 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. In this case, the CPT Code Manual definition of code 97760 is orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes. We find that CPT code 97760 is not supported in the medical record. Specifically, this code was not billed with the appropriate modifier. This code required a therapy modifier of GP, GO, or GN. Based on this information, we decided that Medicare rules for coverage of the orthotic(s) management and training services have not been met. Therefore, we decided that the Plan does not have to pay for the orthotic(s) management and training services coded 97760 provided on June 20, 2019.