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

We decided that the Plan does not have to pay for the telephone evaluation service provided on May 12, 2020.

You asked the Plan to pay for the telephone evaluation service. You say that there was no adequate timeframe to obtain authorization and the service is medically necessary. The Plan denied your request. The Plan says this service done by an out-of-network provider and the services are not urgent or emergent nor approved in advance.

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 the telephone evaluation service provided on May 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves (L1833, L2397).

You asked the Plan to pay for the knee orthoses and suspension sleeves. You say that the items provided were medically necessary. The Plan denied your request. The Plan says the provider did not have a video or telephonic visit with the enrollee prior to the items being ordered.

The Plan follows Medicare rules. Medicare rules say that for the knee orthosis to be covered, knee instability must be documented by examination of the beneficiary and objective description of joint laxity.

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 knee orthoses and suspension sleeves. Our reviewer says that the items were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, 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 the knee orthoses and suspension sleeves have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves (L1833, L2397).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the unspecified preventive service (D1999).

You asked the Plan to pay for the dental services. You say that you went to the a previous dentist for a regular cleaning but they wanted to do a deep cleaning for $4,000. You say that a different dentist would do a regular cleaning if you signed off on it so you went there instead. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 years. The Plan says that the frequency limit has been exceeded. The Plan also says that participating providers are receiving a separate monthly stipend for the unspecified preventive service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 comprehensive oral evaluation every 3 years has been exceeded. The record shows that the Plan paid for this service that you received. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the unspecified preventive service (D1999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental image with dental code D0220.

You asked the Plan to pay for dental code D0220. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental code D0220 is not covered under the Plan's supplemental dental benefit.

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, dental code D0220 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental image with dental code D0220.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the SNF services provided on February 7, 2020, through February 14, 2020.

You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a nonparticipating provider must bill their claims with valid 0022 Rev Code along with Patient Driven Payment Model (PDPM) code effective October 01, 2019.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Specifically, this claim has not been submitted with an appropriate revenue code or PDPM code. Therefore, we decided that the Plan does not have to pay for the SNF services provided on February 7, 2020, through February 14, 2020.

We note that it appears a corrected claim was submitted directly to Maximus during the review of this case. We cannot act on or process claim corrections. Corrected claim information may be submitted directly to the Plan for further review. We are only permitted to make a decision based on the claim information reviewed by the Plan for payment. Please submit any corrections or additional claim information directly to the Plan.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan identified with code 74176 provided on August 20, 2020.

You asked the Plan to pay for the CT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 74176 is computed tomography, abdomen and pelvis; without contrast material. 

We find that CPT code 74176 is not supported in the medical record. Specifically, this claim must be billed with a revenue code of 0510 and a type of bill of 13X. This claim was not billed with this required information. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan identified with code 74176 provided on August 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a interspinous and/or interlaminar device (22869).

You asked the Plan to pre-approve a interspinous and/or interlaminar device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 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 interspinous and/or interlaminar device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer 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 a interspinous and/or interlaminar device have not been met. Therefore, we decided that the Plan does not have to pre-approve a interspinous and/or interlaminar device (22869).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myrbetriq tablets.

You asked the Plan to pre-approve Myrbetriq tablets. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Myrbetriq tablets are not covered under your Medicare Part B benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Myrbetriq tablets.

Benefits for Myrbetriq tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure provided on October 13, 2020.

You asked the Plan to pay for the preventive procedure. You say that you feel that this charge should be covered. The Plan denied your request. The Plan says this service is not covered. The Plan also says that participating providers are receiving a separate monthly stipend for the unspecified preventive procedure (D1999).

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 preventive procedure provided on October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Lupron injection to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a Lupron injection to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says the services can be provided in-network. Therefore, coverage criteria has not been met.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a Lupron injection to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation and first intraoral periapical x-ray provided by an OON provider.

You asked the Plan to pay for the comprehensive periodontal evaluation and first intraoral periapical x-ray. You say that your in-network dentist referred you to this provider. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that services performed by an OON provider are not covered because your healthcare plan does not have OON benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation and first intraoral periapical x-ray provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Finally, there is not a reasonable expectation that this patient 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cataract removal services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve services with an out of network provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out of network care. The Plan says there are in-network providers available to you that can perform cataract removal surgery.

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 the cataract removal services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injections.

You asked the Plan to waive the coinsurance for the Part B injections. You say that you were not informed of the cost for the injections. 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 20% coinsurance plus any applicable copayment, depending on the location of service for Medicare Part B drugs.

You have been asked to pay a total of $1,092.80 for the Part B injections. The Part B injections fall within the "Medicare Part B prescription drugs" benefit category. See chart provided.

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 for the Part B injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on September 3, 2020.

You asked the Plan to pay for the dental service. You say that the service should be covered. You also say that the name of the provider and the details of the service are missing. The Plan denied your request. The Plan says the consultation is not listed as a covered service. The Plan also says that you did not contact them to verify your benefits and provider eligibility.

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 consultation (D9310) provided on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit.

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 claim 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 these services was not filed. The valid Waiver of Liability (WOL) was not received. 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 office visit.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the ultrasound.

You asked the Plan to reduce the copayment for the ultrasound. You say that there should be a $45 copayment because it was confirmed that the medical center was an in-network freestanding radiology facility. 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 $110 copayment for basic radiological services at an in-network outpatient hospital.

You have been asked to pay a $110 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows that the provider is an outpatient hospital. 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 reduce the copayment for the ultrasound.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy visits.

You asked the Plan to pay for the psychotherapy visits. You say that you were told this service was covered. The Plan denied your request. The Plan says the services were received by an out-of-network provider and the services were not urgent or emergent nor approved in advance.

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 the psychotherapy visits.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the acupuncture services.

You asked the Plan to pay for the acupuncture services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are 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. In this case, the Plan is denying payment for the acupuncture services because the provider is not supervised by any physician, PA, or NP/CNS; however, the Plan provided no documentation showing this to be the case. We find that the Plan has not provided enough information to substantiate their reasoning for denial of payment. Therefore, we decided that the Plan has to pay for the acupuncture services.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe adjunctive pre-diagnostic test and topical application of fluoride varnish provided on August 29, 2019.You asked the Plan to pay forthe adjunctive pre-diagnostic test and topical application of fluoride varnish. You say that you went to an in-network provider and everything should have been fully covered except for the cancer screening which you paid for.The Plan denied your request. The Plan says these services are not covered.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. The record shows that the Plan contacted the provider and were advised that you have a zero balance for these services.Therefore, we decided that the Plan does not have to pay forthe adjunctive pre-diagnostic test and topical application of fluoride varnish provided on August 29, 2019.