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

We decided that the Plan does not have to pay for hearing aids (V5298) purchased December 31, 2019 from an
out-of-network provider.
You asked the Plan to pay for the hearing aids. You say that your plan does cover out-of-network hearing aids
services and you would like the claim reconsidered accordingly. The Plan denied your request. The Plan says
hearing aids purchased from an out-of-network hearing aid vendor is not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for
hearing aids (V5298) purchased December 31, 2019 from an out-of-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided from January 6, 2020
to January 8, 2020.
You asked the Plan to waive the copayment for an ER visit. You say that you should not be responsible for the
charges because you were admitted inpatient. The Plan denied your request. The Plan says the claims were
processed correctly and you are being charged the correct amount.
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 $120
copayment for emergency care.
The medical records show that you had an observation stay following an ER visit from January 6, 2020 to
January 8, 2020. An observation stay is not considered an inpatient hospital admission. Therefore, you are
responsible to pay the $120 copayment.
You have been asked to pay a $120 copayment for an ER visit. An ER visit falls within the emergency care
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 an ER visit provided from
January 6, 2020 to January 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the records provided support the need for SNF care.The Plan denied your request. The Plan says the criteria for coverage of SNF care have not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received enteral nutrition and medications, had stable vital signs, clear lungs, and was treated for a UTI. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was contact-guard to stand-by assist level with functional mobility, including gait to 875 feet and negotiation of 2 flights of stairs. The enrollee required varying assist with activities of daily living. There are identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. However, the enrollee does not require skilled nursing or skilled therapy services on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean oxygen concentrator (CPT E1390).You asked the Plan to pre-approvethe oxygen concentrator. You say that you submitted the blood work requested and there are no additional medical notes.The Plan denied your request. The Plan says the requested oxygen concentrator does not meet the definition of medically necessary. The Plan says that they have not received documentation with qualifying test results.The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.  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 oxygen concentrator. Our reviewer says that the criteria for coverage of a home oxygen concentrator have notbeen met. Our physician reviewer found the overnight oximetry does not show that the saturation is at or below 88% for at least 5 minutes. Home oxygen supplementation is not medically necessary.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 oxygen concentrator have not been met.Therefore, we decided that the Plan does not have to pre-approvean oxygen concentrator (CPT E1390).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the mammogram and the ultrasound provided on March 19, 2019.
You asked the Plan to waive the copayments for the mammogram and the ultrasound. You say that you did not have a second mammogram or an ultrasound. You say you do not believe you should be billed. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $40 copayment for each basic imaging service (e.g., general x-rays or ultrasound). You have been asked to pay a $40 copayment for the mammogram and a $40 copayment for the ultrasound. The mammogram and the ultrasound fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows you received a diagnostic mammogram and an ultrasound of the left breast.
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 copayments for the mammogram and the ultrasound provided on March 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (J3010) provided on October 31, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed service cannot be verified.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 J3010 is "J3010 -Injection, fentanyl citrate, 0.1 mg".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 the services. Our reviewer says that the use of code J3010 is not supported by the records provided. Our physician reviewer found that the documentation submitted was reviewed, and does not indicate that an "injection, fentanyl citrate, 0.1 mg" was given on the date of service in question.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 pay forthe services (J3010) provided on October 31, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSynvisc-One.You asked the Plan to pre-approveSynvisc-One. You say that the Synvisc-One is medically necessary.The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefullyreview the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Synvisc-One. Our reviewer says that the Synvisc-One is not medically necessary. Our physician reviewer found the records do not show a trial of the plan preferred drugs or any reason why they would be ineffective or unsafe 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 Synvisc-One have not been met.Therefore, we decided that the Plan does not have to pre-approveSynvisc-One.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 16 additional physical therapy (PT) visits.
You asked the Plan to pre-approve 16 additional PT visits. You say that the requested 16 additional PT visits are medically necessary. The Plan denied your request. The Plan says the requested 16 additional PT visits are not medically necessary.
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 pre-approve 16 additional PT 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 requested additional 16 visits of therapy would not be generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the plan. The enrollee has had extensive therapy and should be able to transition to an independent home exercise program. The records do not demonstrate that the enrollee's deficits require 3 times a week therapy with unique skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist beyond that which was already approved by the plan. 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 enrollee'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 16 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 16 additional physical therapy (PT) visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of implant services provided on September 27,
2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the removal
of implants is not separately reportable if the removal is a necessary integral component of another procedure.
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 20680 is removal of implant; deep (eg, buried wire, pin,
screw, metal band, nail, rod or plate). We asked our coding 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 services
provided. Our reviewer says that the removal of implants is not reported separately if the removal is a
necessary integral component of another procedure.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan
does not have to pay for the removal of implant services provided on September 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 9, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for genetic testing. You say that this test was ordered by the physician to determine
the optimal treatment pathway for the enrollee. The Plan denied your request. The Plan says the denial of
payment for these services is correct, because this provider is out-of-network with the Plan and the ordering
physician 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 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 March 9, 2020
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 22,
2020.
You asked the Plan to waive the copayment for a specialist visit. You say that the visit lasted 5 minutes and the
physician did not treat your condition and referred you to another provider. The Plan denied your request. The
Plan says the claims were processed correctly and you are being charged the correct amount.
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 $35
copayment for specialist visits.
You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits 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 specialist visit provided on January 22, 2020.
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit
MAXIMUS to make a decision on this type of complaint.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forparavertebral facet joint injections (64495) provided on December 5, 2019.You asked the Plan to pay forparavertebral facet joint injections. You say that this is shown in the operative report.The Plan denied your request. The Plan says this code is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 64495 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure).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 paravertebral facet joint injections. Our reviewer says that this code is not supported. Our physician reviewer found the medical records submitted indicate that injections were made at L3-L4, L4-L5. This validates that 2 facet joints were blocked, therefore, this service cannot be validated.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of paravertebral facet joint injections have not been met.Therefore, we decided that the Plan does not have to pay forparavertebral facet joint injections (64495) provided on December 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

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

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services could be provided in another setting, such asan acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting, or home care.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriatefor 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 enrollee is currently undergoing treatment at an ACH following emergency surgery for a perforated colon. The enrollee was transiently intubated/ventilated, but has since been extubated and is no longer on a ventilator. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level ofcare, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing longterm care needs.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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 10, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you were there for 2-3 minutes
to get results and disagree with the charges. The Plan denied your request. The Plan says the claims were
processed correctly and you are being charged the correct amount.
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 $50
copayment for specialist visits.
You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits 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 specialist visit provided on July 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on March 5, 2020.
You asked the Plan to pay for the periodontal maintenance. You say that this is an available benefit. The Plan
denied your request. The Plan says this service is not a Medicare covered benefit. The Plan also says that
periodontal maintenance is not considered preventive.
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
periodontal maintenance provided on March 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ultrasound rendered on December 6, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 76641 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 76641 is ultrasound, breast, unilateral, real time with image documentation, including axilla whenperformed; complete.We find that CPT code 76641 is not supported in the medical record. Specifically, the submitted medical records have been altered and do not support that the services were performed for the date of service at issue. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe ultrasound rendered on December 6, 2019.