Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for facet joint injections (64494) provided on October 5, 2020.
You asked the Plan to pay for the facet joint injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the units billed exceed Medicare's Unlikely Edits guidelines.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 64494 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the facet joint injections have not been met.
Therefore, we decided that the Plan does not have to pay for facet joint injections (64494) provided on October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have been wearing orthotics for quite some time and are in need of a new pair. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 2 dental x-rays (D0272) provided February 23, 2021.

You asked the Plan to pay for the x-rays. You say that the x-rays were medically necessary. The Plan denied
your request. The Plan says the benefit for x-rays was exhausted at the time of 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, coverage for x-rays is limited to one
set of x-rays every 12 months. Therefore, we decided that the Plan does not have to pay for 2 dental x-rays
(D0272) provided February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three crowns (D2740 x3), four core buildups, including any pins when required (D2950 x4), two pontics (D6240 x2), and a retainer crown (D6750).
You asked the Plan to pre-approve the crowns, core buildups, pontics, and retainer crown. The Plan denied your request. The Plan says these services 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 three crowns (D2740 x3), four core buildups, including any pins when required (D2950 x4), two pontics (D6240 x2), and a retainer crown (D6750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on January 13, 2021.
You asked the Plan to pay for the panoramic x-ray. You say that you would like this service to be covered. The Plan denied your request. The Plan says this procedure is not covered under your dental 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 pay for the panoramic x-ray (D0330) provided on January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L1833 and L2397) billed to the enrollee for date of service August 25, 2020.

You asked the Plan to pay for these orthoses. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage and billing criteria were 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 orthoses billed to the enrollee. The Maximus Reviewer determined these items to be necessary. The Plan argues the required evaluation criteria were not met. The medical records show this was a the 51-year-old man with a diagnosis of unilateral primary osteoarthritis.

Our Medical Director has concluded that the Plan is correct in this case. The available documentation in the case file does not support that the requested orthoses were medically reasonable and necessary. An appropriate history and a physical examination would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the orthoses provided were prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee. There is insufficient documentation of a credible physical examination. Based on the records provided, Medicare coverage criteria were not met.

We looked at our Medical Directors review, the case file, the reopen and the Medicare rules. Based on this information we have decided criteria for payment of this claim were not met. Therefore, we decided that the Plan does not have to pay for orthoses billed to the enrollee for date of service August 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for positron emission tomography (PET) scan.
You asked the Plan to provide coverage for a positron emission tomography (PET) scan. You say that this imaging 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 coverage criteria.
Our Medical Director reviewed the case file and the reopen request. At issue is coverage for a PET scan. The Maximus Physician Reviewer determined that an Axumin PET scan is prostate specific and would be the safest and best single test to determine if the therapy the patient is on currently is sufficient or whether target radiation therapy should be considered. The Plan argues that NCD 220.6.17 states that a PET scan is not covered for the initial treatment strategy for prostate cancer. Our Medical Director has concluded that the Plan is correct in this case. NCD 220.6.17 states that coverage for FDG PET in the evaluation of prostate cancer is non-covered for initial treatment strategy. Medicare coverage criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a positron emission tomography (PET)scan have not been met. Therefore, we decided that the Plan does not have to provide coverage for positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a padded commode with armrests.
You asked the Plan to pre-approve the requested item. You say that without the equipment, the enrollee is at higher risk for skin breakdown, bowel impaction, and falls. The Plan denied your request. The Plan says coverage criteria have not been met.
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are confined to a bed or room. The file does not show that the enrollee is confined to a bed or room as defined by Medicare rules. Therefore, we decided that the Plan does not have to pre-approve a padded commode with armrests.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 8, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.
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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography Angiography (CTA) scan to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve CTA scan. You say that the enrollee has not had any recent evaluation of his condition. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and this testing can be performed by an in-network provider.
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 a Computed Tomography Angiography (CTA) scan to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical assistant services provided on December 2, 2020 billed with code 20670.
You asked the Plan to pay for the surgical assistant services. You say that this should be paid due to medical necessity. The Plan denied your request. The Plan says as surgical assistant payment is allowed for code 25609, this was approved for payment. However, Medicare does not allow payment for this for code 20670.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered.
In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 20670. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical assistant services provided on December 2, 2020 billed with code 20670.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the eye exam and testing provided on January 7, 2021.

You asked the Plan to waive the cost sharing for the eye exam and testing. You say that you think this should be waived because you are covered for one annual eye exam in full, and you were not informed that having diabetes is an exception to that $0 co-payment. The Plan denied your request. The Plan says as this exam was performed for evaluation of ocular allergies, it is not considered a routine eye exam but a medical eye exam for which a co-payment applies.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 co-payment for an eye exam to diagnose and treat diseases and conditions of the eye.

You have been asked to pay a $20 co-payment for the eye exam and testing. These services fall within the eye exam to diagnose and treat diseases and conditions of the eye benefit category. A routine eye exam is considered one that is solely for checking vision and providing eyewear or contacts. Since you were evaluated for a medical condition, this visit was not considered a routine exam. 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 cost sharing for the eye exam and testing provided on January 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF services. You say that the enrollee can't get out of bed. The Plan denied your request. The Plan says the enrollee does not require therapy 5 days a week.
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 services. Our physician reviewer found that from a nursing perspective, you received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at a modified independent to supervision level with functional mobility. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide 20 additional physical therapy visits.
You asked the Plan to provide 20 remaining physical therapy visits. You say that the enrollee has made progress but needs more physical therapy to slow the progression of disease. The Plan denied your request.
The Plan says they will approve 8 additional visits, but the enrollee does not meet the medical necessity criteria for the continuation of rehabilitative physical therapy services for the remaining 20 visits.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 provide 20 remaining physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the patient has had prior extensive outpatient therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The patient has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 20 remaining physical therapy visits have not been met. Therefore, we decided that the Plan does not have to provide 20 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) for tooth #19.
You asked the Plan to pre-approve the core buildup for tooth #19. You say that you would like the service covered. The Plan denied your request. The Plan says this service is not covered under your dental 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 core buildup, including any pins when required (D2950) for tooth #19.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) is not covered. We looked at the file and Medicare rules. The requested power seat elevation system is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued care with an out-of-network (OON)
orthopedic surgeon.
You asked the Plan to pre-approve continued care with an out-of-network (OON) orthopedic surgeon. You say
that the continued care with the enrollee's out-of-network (OON) orthopedic surgeon is medically necessary.
The Plan denied your request. The Plan says the continued care with the enrollee's out-of-network (OON)
orthopedic surgeon is not medically necessary.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you
must use contract providers for care.
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 continued care with an out-of-network
(OON) orthopedic surgeon. Our reviewer says that the continued care with the enrollee's out-of-network
(OON) orthopedic surgeon is not medically necessary. Our physician reviewer found the enrollee is not
currently receiving any active treatment and/or medical management of his condition that makes it medically
necessary for this enrollee to continue care with the out-of-network orthopedic surgery provider as requested.
There is not anything unique about this enrollee's condition that would make it medically necessary for him to
continue with the OON specialist. There are no extenuating findings that would require specialized treatment
for the enrollee's condition at this time, based on the medical documentation provided for review. The plan has
shown that it has in-network orthopedic specialists who have the qualifications and expertise necessary to meet
the current medical Standards of Care required for treatment of the enrollee's condition. This enrollee's
medical management and/or follow-up care can be safely transitioned to an in-network orthopedic surgery
specialist at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued care with an out-of-network (OON) orthopedic surgeon have not
been met. Therefore, we decided that the Plan does not have to pre-approve continued care with an out-of-network
(OON) orthopedic surgeon.