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

We decided that the Plan does not have to pay for neuromonitoring services (95999) provided August 13, 2020.

You asked the Plan to pay for the neuromonitoring services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not separately payable.

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 95999 is Unlisted neurological or neuromuscular diagnostic procedure. 

We find that CPT code 95999 is not supported in the medical record. Specifically, payment for this service was bundled in payment for the primary procedure. Based on this information, we decided that Medicare rules for
coverage of the neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95999) provided August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 19, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the member's primary care physician did not refer these services.

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 physician services provided on February 19, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 5, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records do not indicate that the specimen was collected in a laboratory setting. This means that the claim was billed with the incorrect POS code. 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 May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64633).

You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when 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 injections. Our reviewer says that the requested injections are not medically necessary. Our physician reviewer found for coverage to be approved, a treatment plan must show the region (upper, middle, or lower back) and levels of your spine to be treated, and no more than two levels of your spine can be treated on the same day. The treatment plan does not document this. 

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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64633).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a treatment of radial (lower-arm bone) head
or neck fracture (24650) received on February 19, 2021.

You asked the Plan to waive the deductible for a treatment of radial head or neck fracture. You say that you
should not be liable for this cost sharing because all the physician did was touch your arm below the elbow and
tell you that you had a fracture. The Plan denied your request. The Plan says the correct cost sharing was
applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $750 deductible for outpatient surgery and/or services at an
ambulatory surgical center or outpatient hospital facility.

The item or service you asked the Plan to waive the deductible for falls within the "Outpatient surgery,
including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

This cost sharing is a contractual obligation that had not been met at the time a treatment of radial head or neck fracture was received on February 19, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a treatment of radial (lower-arm bone) head or neck fracture (24650) received on February 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81226, 81230, 81231, 81240, 81241, 81328, 81408) provided on August 26, 2020.

You asked the Plan to pay for genetic testing. You say that this testing is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. 

We find that CPT codes 81226, 81230, 81231, 81240, 81241, 81328, and 81408 are not supported in the medical record. Specifically, the records show that the testing at issue was performed as a panel, meaning it should be reported with a single code. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81226, 81230, 81231, 81240, 81241, 81328, 81408) provided on August 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87481, 87640, 87500) provided on February 15, 2021 by an out of network (OON) provider.

You asked the Plan to pay for OON laboratory services. You say that this testing is a Medicare-covered service. The Plan denied your request. The Plan says this was 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 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 services (87481, 87640, 87500) provided on February 15, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $45 copayments charged for INR services provided from
January 13, 2020 to September 21, 2020.

You asked the Plan to waive these copayments. You say that you should only pay for the supplies to test, not an
office visit. The Plan denied your request. The Plan says this cost share was charged based on the services
billed by your provider and your Plan contract agreement. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct contract language.

The Plan is correct in this case. 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 $45 copayment for specialist physician services.

When you send in your results or specimen or information to be reviewed, it requires a professional service to
process this information for you. Your provider has submitted a claim for these services. Therefore, a
copayment for each service applies. 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 $45 copayments charged for INR services
provided from January 13, 2020 to September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be rendered by an out of network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.

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. 

You are not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve office visits to be rendered by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral to an orthopedic surgeon.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is no network gap or continuity circumstance.

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 an out-of-network referral to an orthopedic surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care and hospital discharge day management provided on December 27, 2020.

You asked the Plan to pay for hospital discharge day management; more than 30 minutes (99239). You say that the Plan should pay this claim. The Plan denied your request. The Plan says records are still needed to substantiate more than 30 minutes of discharge day care time.

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 99239 is hospital discharge day management; more than 30 minutes.

We find that CPT code 99239 is not supported in the medical record. Specifically, this is a time-based code and the records support less than 30 minutes of care. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management; more than 30 minutes (99239) have not been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care and hospital discharge day management provided on December 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the surgery is necessary. The Plan denied your request. The Plan says the services are 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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device.

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.

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 step therapy requirement is not met.

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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has knee pain. She has not tried and failed the Plan's required drugs, of Durolane, Euflexxa, Supartz, and Gel-Syn 3. The records do not show that the required drugs would be contraindicated or less effective; therefore, Gel-One is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the copayments charged for INR physician services
provided from March 24, 2020, to December 22, 2020.

You asked the Plan to waive or reduce this cost share. You say that you process a kit and send it into the
physician's office. You say there should be no charge for sending in this information. The Plan denied your
request. The Plan says this cost share was charged per your Plan contract agreement. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus applied the incorrect contract language.

The Plan is correct in this case. 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 $30 copayment for specialist physician or staff services.

When you send in your results or specimen or information to be reviewed, it requires a professional service to
process this information for you. Therefore, a copayment for each service applies. 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 or
reduce the copayments charged for INR physician services provided from March 24, 2020, to December 22,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1833) and suspension sleeve (L2397) provided on September 29, 2020.

You asked the Plan to pay for a knee brace and suspension sleeve. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the provided records do not support the service billed.

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 pay for a knee brace and suspension sleeve. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee brace have not been met. Furthermore, the suspension sleeve at issue is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for a knee brace (L1833) and suspension sleeve (L2397) provided on September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 19, 2020 by an out of network provider.

You asked the Plan to pay for the office visit. You say that the Plan should reprocess the claim towards payment. The Plan denied your request. The Plan says you did not obtain prior authorization.

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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit provided on March 19, 2020 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on June 11, 2020.

You asked the Plan to pay for the lab testing. You say that you received blood samples that are drawn at the physician's office and sent to the laboratory to be processed. You feel that the POS code used is correct. The Plan denied your request. The Plan says the POS code for this claim is not supported. It should be reported as POS 11.

The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 

In this case, the documentation supports this sample was drawn in the physician's office, not by the independent laboratory. As such, POS code 81 is not supported. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on June 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of hypertension, arthritis and trochanteric bursitis. you are living at home and receiving home health care. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).