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

We decided that the Plan does not have to pay for the chiropractic services.

You asked the Plan to pay for the chiropractor services. You say that you went to the chiropractor paid by credit card at the time of the visits. They were not in network. You specified benefits to be paid to you, not the provider and the plan has denied the claims multiple times. The Plan denied your request. The Plan says the claims were processed and the correct cost share was applied per the plan's Evidence of Coverage. Office visits are not covered if rendered by a chiropractor.

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 40% coinsurance for out of network chiropractic services for 2019 and 50% coinsurance for out of network chiropractic services for 2020.

You have been asked to pay $220 for the chiropractor services. You have an $800 deductible. This is the amount you have to pay out of pocket before the plan will pay their share for covered medical services. Since you did not meet the $800 deductible, you are responsible for the cost of these services. The records show that the chiropractor services fall within the Chiropractic services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for the chiropractic services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
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 medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain and sacroilitis. The requested RFA of the SI joint is considered experimental/investigational in nature due to wide variation in efficacy. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond of an implant/abutment supported crown or pay more for the resin-based composite of three surfaces.

You asked the Plan to pay for the re-cement or re-bond of an implant/abutment supported crown and to pay more for the resin-based composite. You say that you would like these services to be covered. The Plan denied your request. The Plan says the re-cement or re-bond of an implant/abutment supported crown is not a covered benefit. The Plan also says that you are responsible for the difference between the allowed amounts for the resin-based composite.

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 re-cement or re-bond of an implant/abutment supported crown is not among those covered under this benefit. The contract also clearly states that white fillings (back teeth) are covered once every 24 months per surface, per tooth; multi-surfaces will be processed as a silver filling and the enrollee is responsible up to the contracted fee. The record shows that you received a resin-based composite of three surfaces on tooth #2, which is a back tooth. The resin-based composite was charged as an alternate benefit of an amalgam, per your EOC, and you are responsible for a 20% coinsurance plus the difference between the allowed amounts of the amalgam and resin based composite. Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond of an implant/abutment supported crown or pay more for the resin-based composite of three surfaces.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that molecular genetic screening testing is not a Medicare Benefit for the diagnoses listed.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab testing services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office services (CPT code 99212) provided to the enrollee by a non-participating provider.

You asked the Plan to pay for the office services. You say that the claim should be paid. The Plan denied your request. The Plan says that their records show an approved authorization of file for this enrollee however, either the services performed, the servicing provider and or the number of visits approved on the authorization do not match what was approved on the authorization; therefore, the service is not covered.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. It appears that the plan's contracted delegate did not provide sufficient information that would verify the services were approved or any information that would corroborate their denial. Therefore, we decided that the Plan has to pay for the office services (CPT code 99212) provided to the enrollee by a non-participating provider.

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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital visits: Initial and subsequent (99223).

You asked the Plan to pay for inpatient hospital visits. You say that in this case, services were rendered by 2 different clinicians with 2 distinct specialties. Since these are 2 different specialties, both clinicians are entitled to separate reimbursement. The Plan denied your request. The Plan says the submitted documentation supports 1 unit of 99223, which was previously approved and paid.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.

We find that 1 units of CPT code 99223 are not supported in the medical record. The medical record only supports 1 units of CPT code 99223 which was already paid and approved by the plan. Based on this information, we decided that Medicare rules for coverage of inpatient hospital visits have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital visits: Initial and subsequent (99223).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electroencephalogram with video (VEEG) (95713).
You asked the Plan to pre-approve a VEEG. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 a VEEG. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested study would not be readily consistent with the generally accepted standards of practice or care. Such services would also exceed your clinical needs at this time. For these reasons, the services provided would not be 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 a VEEG have not been met. Therefore, we decided that the Plan does not have to pre-approve an electroencephalogram with video (VEEG) (95713).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

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 age-related osteoporosis without current pathological fracture. She has not tried and failed the Plan's required drug, Zoledronic acid. The records do not show that the required drug would be contraindicated or less effective; therefore, Prolia 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 Prolia.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve myocardial perfusion imaging (78452).
You asked the Plan to pre-approve myocardial perfusion imaging. You say that the requested services are
medically necessary for you. The Plan denied your request. The Plan says that the requested services are not
medically reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 myocardial perfusion imaging. Our
reviewer says that the requested items/services are considered medically reasonable and necessary in this case.
Our physician reviewer found that you have hypertension, hyperlipidemia, and exertional shortness of breath
symptoms. You have been referred for Lexiscan nuclear stress testing because of inability to walk on a
treadmill due to chronic back pain. You have a number of risk factors for coronary artery disease and
symptoms of exertional dyspnea, possibly an anginal equivalent. You cannot exercise and so require
pharmacologic stress testing. Based on your symptoms and inability to exercise on a treadmill due to chronic
back issues, a Lexiscan nuclear single-photon emission computerized tomography (SPECT) stress test is
medically reasonable and necessary and meets the Medicare criteria for myocardial imaging for assessment of
the functional and prognostic importance of angina.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of myocardial perfusion imaging have been met. Therefore, we decided that the
Plan has to pre-approve myocardial perfusion imaging (78452).
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on March 30, 2021 with septic shock related to a stage IV decubitus ulcer. He has a wound vac in place and several other wounds with non-complicated dressings and care. There is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the device implantation.
You asked the Plan to pre-approve implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components (C2624) and transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed (33289). You say that current standard of care has not been effective. The Plan denied your request. The Plan says the efficacy of this device is still uncertain at this time.
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 implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components (C2624) and transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed (33289). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested heart failure monitor is indicated for wirelessly measuring and monitoring pulmonary artery (PA) pressure and heart rate in New York Heart Association (NYHA) Class III heart failure patients who have been hospitalized for heart failure in the previous year. The documentation does not support that the enrollee in this case currently has New York Heart Association (NYHA) Class III heart failure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components (C2624) and transcatheter implantation of wireless pulmonary artery pressure
sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed (33289) have not been met. Therefore, we decided that the Plan does not have to pre-approve the device implantation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the place of service on claim must reflect the location of the patient when the specimen was obtained.

The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the claim was submitted with a laboratory place of service code but the record indicates that the member's face-to-face services was rendered in an office setting. There is a more appropriate place of service code for the services billed. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered on from June 8, 2020 to June 11, 2020.
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 the claims were billed incorrectly.
The Plan must follow Medicare rules. The rules say that Medicare requires all home health agency billing claims to be submitted on the Form CMS-1450 hard copy form (also known as the UB-04). We looked at the file and Medicare rules. The file shows that the claims were not submitted on the required CMS-1450/UB-04 form. 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 home health services rendered on from June 8, 2020 to June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the cost share charged by the out of network provider for dental services rendered on September 24, 2020.
You asked the Plan to pay this cost share. You say that you do not believe these charges are correct. The Plan denied your request. The Plan says these claims were paid based on the services provided and the Plan contract agreement. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that the provider is billing you for both your 80% and additional costs already paid by the Plan. The Plan states that because this is an out of network provider, they are unable to demand they stop doing so.
The Plan is correct in this case. 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. For out of network dental services, the Plan pays 20% and enrollees pay 80%. In this case your provider is billing you for services paid by the Plan. Because you did not use a provider contracted with the Plan, the Plan has no recourse on your behalf for this billing. Medicare does cover dental services and also cannot instruct the provider to adjust its billing. Therefore, we decided that the Plan does not have to pay the cost share charged by the provider for dental services rendered on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on January 15, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says The Plan says this claim was not filed timely. Maximus overturned the Plans denial stating a claim could be submitted within 365 days. The Plan requested a reopen and stated that Per CMS guidelines, MMP encounter timeliness submissions differ from Medicare Advantage submission. Encounters should be submitted 180 days from the date of service for MMP plans and the enrollee is an MMP member. The Plan included the guidance on CMS.gov that explains this as additional information. The Plan is correct in this case. The Plan follows Medicare rules. The rules say that in regard to claims for services furnished to MMP members, those claims must be filed within 180 days of the date of service. The record shows that this claim was not filed within 180 days of the date of service. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing services provided to the enrollee on June 17, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan states this claim denied because denied because the provider was not eligible for payment of this service. The Plan states the NPI Registry website shows this provider has a registered with taxonomy as a Nurse Practitioner. However, the provider did not bill with this taxonomy. The Plan included the additional pages of the claim that show the provider billed with a Registered Nurse taxonomy. Medicare billing criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due to a discrepancy with the taxonomy code. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for nursing services provided to the enrollee on June 17, 2020.