Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and attachments for the enrollee.
You asked the Plan to pre-approve a Group 3 power wheelchair and attachments. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair and attachments for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc.You asked the Plan to pre-approve Genvisc. The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.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 Genvisc. Our reviewer says that the enrollee has not met the step therapy requirement for coverage of the requested Genvisc. Our physician reviewer found that while the enrollee has previously used Orthovisc, there is no evidence that the enrollee has previously used Monovisc. There is no evidence that the enrollee is allergic to or intolerant of these other forms of hyaluronic acid. There is no evidence that the enrollee has tried Monovisc or not responded to Orthovisc. There is no documentation as to why these other forms of hyaluronic acid would not be expected to be safe and effective for the 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 Genvisc have not been met.Therefore, we decided that the Plan does not have to pre-approve Genvisc.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital services provided to the enrollee on January 29, 2019.You asked the Plan to pay for the hospital services. You say that you attempted to file this claim timely.The Plan denied your request. The Plan says that this was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the hospital services was not filed until February 1, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for the hospital services provided to the enrollee on January 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nursing facility care (99309) provided on January 13, 2020 byan out of network (OON) provider.You asked the Plan to pay forOON nursing facility care. You say that this was a medically necessary service provided in good faith.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 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 forthe nursing facility care (99309) provided on January 13, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacral (CPT Code 22015) on August 26, 2019 provided by a non-contracted assistant surgeon.You asked the Plan to pay forthe services. You say that per CMS guidelines the service classifies as a category 1. You state that the assistant physician was present for a substantial portion of the operation, and that this entitles the assistant surgeon to payment on procedure code 22015 modifier 80.The Plan denied your request. The Plan says services of an assistant surgeon, co-surgeon, or surgical team are not covered for this 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.The rules say the assistant surgeon indicator for incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacral (CPT Code 22015) is one (1) which means that statutory payment restriction for assistants at surgery applies to this procedure. Assistant surgery may not be paid. 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 forincision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacral (CPT Code 22015) on August 26, 2019 provided by a non-contracted assistant surgeon.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on March 26, 2020.You asked the Plan to waive the copayment for the laboratory services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received laboratory services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.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 $10 copayment for each Medicare-covered lab test. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a second urine test on March 26, 2020. You have been asked to pay a $10 copayment for the urine test. The urine test falls within the Outpatient diagnostic tests 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 the laboratory services provided on March 26, 2020.Your complaint about you not providing a second sample is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray, problem focused limited oral evaluation, add tooth to existing partial denture, diagnostic casts, and extraction provided on January 16, 2020 by an OON provider.You asked the Plan to pay forthe dental services. You say that you contacted the Plan prior to receiving these services to inquire if you could be reimbursed for going to another dentist. You also say that the Plan representative advised that it is possible that the reimbursement would be approved.The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that you must use network providers to receive dental services.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 covered when they are received OON. The records show that the Plan received a signed treatment plan from the treating dentistwhich indicates you acknowledged and accepted financial responsibility prior to receiving the dental services.Therefore, we decided that the Plan does not have to pay forthe first intraoral periapical x-ray, problem focused limited oral evaluation, add tooth to existing partial denture, diagnostic casts, and extraction provided on January 16, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on February 26, 2020.
You asked the Plan to waive the copayment for an MRI. You say that you never paid for an MRI in the past 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 $250 copayment for diagnostic radiology other than CT scans. You have been asked to pay a $250 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies 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 MRI provided on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the services rendered from March 10, 2020 to March 20, 2020.
You asked the Plan to waive the deductible for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claims were processed correctly.
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 $1,300 yearly deductible for covered medical services. The item or service you asked the Plan to waive the deductible for falls within the out-of-network PCP's office services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,300 yearly deductible for covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on March 10, 2020 to March 20, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the services rendered from March 10, 2020 to March 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 20, 2020.You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the provider is ineligible to bill Medicare.The Plan must follow Medicare rules. The rules say no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. The file shows the medical services were provided by a provider that has not enrolled in the Medicare program.Therefore, we decided that the Plan does not have to pay for the medical services provided on February 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on October 17, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 for the definitive drug testing rendered on October 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva (Denosumab).You asked the Plan to pre-approve Xgeva (Denosumab). 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 medically necessary.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 Xgeva (Denosumab). Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of osteoporosis. The documentation does not support that pamidronate or zoledronic acid have been tried and failed. The documentation does not support that pamidronate or zoledronic acid would likely beless effective, and/or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xgeva (Denosumab) have not been met.Therefore, we decided that the Plan does not have to pre-approve Xgeva (Denosumab).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulatory surgical boot (L3260) provided on October 14,
2019 by an out-of-network provider. You asked the Plan to pay for the surgical boot. You say that the durable medical equipment is medically
necessary. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health
Plan.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This
provider has opted out of the Medicare program. The plan confirmed that this provider is not included in
Medicare's Supplier Directory as a certified provider. The item you received is also not included in the
DMEPOS (Durable Medical Equipment Prosthetics, Orthotics and Supplies) list of covered services. Therefore,
we decided that the Plan does not have to pay for ambulatory surgical boot (L3260) provided on October 14,
2019 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the enrollee on July 3, 2019.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests are to be performed.

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 HCPCS code G0482 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed."

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 services at issue in this case were not supported by the medical records. Our physician reviewer found the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests are to be performed. In addition, the submitted Laboratory Requisition indicates that a Toxicology Profile R019 Panel was requested. The submitted documentation does not itemize what tests are included in this panel. The review has determined that the records do not support the above denied code. The records do not contain a valid physician order/requisition to support G0482.

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 for drug testing services (HCPCS G0482) provided to the enrollee on July 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Visudyne injection provided January 27, 2020.You asked the Plan to waive the coinsurance for the injection. You say that you were never told there would be a copayment.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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Part B Drugs. You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Part B Drugs 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 coinsurance fora Visudyne injection provided January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe non-emergency transportation, mini bus (A0120) provided December 13, 2019.You asked the Plan to pay forthe transportation. You say that the enrollee had brain surgery and required a special kind of gurney when discharged. They transportation provider required payment of $695 upfront and you are requesting reimbursement.The Plan denied your request. The Plan says this was not a medical transport. The transport was for convenience purposes for the enrollee to be closer to home.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation have not been met.Therefore, we decided that the Plan does not have to pay forthe non-emergency transportation, mini bus (A0120) provided December 13, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the definitive drug testing for 15-21 drug classes provided on August 12, 2019 billed with code G0482.You asked the Plan to pay for the definitive drug testing. You say that the documentation shows that this was ordered by the treating provider and was performed based on that order. This was medically necessary and should be paid.The Plan denied your request. The Plan says that the report does not show that 15-21 drug classes were tested.Please note: The Plan based this count on the drug classes listed in the LCD L36668. The text of the LCD does not indicate that this is an exhaustive list of billable drug classes or that this should be used when reviewing the number of drug classes tested vs. those reported via the CPT code. Maximus used the drug/drug class listing as defined by the CPT Manual. 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 G0482 is Drug test(s), definitive, utilizing (1) drug identification methods able to identifyindividual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit,fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed.We find that CPT code G0482 is supported in the medical record. Specifically, the lab was reviewed and compared to the AMA CPT Manual and it was found that at least 15 drug classes as defined in this manual were listed as being tested. Based on this information, we decided that Medicare rules for coverage of the definitive drug testing have been met.Therefore, we decided that the Plan has to pay forthe definitive drug testing for 15-21 drug classes provided on August 12, 2019 billed with code G0482.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.