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

We decided that the Plan does not have to pay for practitioner services billed for dates of service September 24,
2020 to October 6, 2020.

You asked the Plan to pay for these claims. You say that these services should be paid by the Plan. 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 stated that these claims denied because the provider was not eligible for payment of this service. The Plan
states the NPI Registry website shows this provider is registered as a "Registered Nurse General Practice" The
claim shows the provider has billed with a Registered Nurse taxonomy. The rendering provider shows the
provider has with the incorrect taxonomy. Therefore, this claim cannot be paid as billed.

The Plan is correct in this case. 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 the claim was
submitted with an incorrect or ineligible taxonomy code. Medicare billing criteria are not met. Based on this
information, we decided that Medicare rules for coverage of these claims have not been met. Therefore, we
decided that the Plan does not have to pay for practitioner services provided to the enrollee billed for dates of
service September 24, 2020 to October 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the PCD (CPT code E0676) provided on April 21, 2021.
You asked the Plan to pay for the PCD. You say that you did not realize the item would not be covered. You state that the device did not work properly so you should not have to pay for it. The Plan denied your request. The Plan says this device is not covered by Medicare.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (CPT code E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for the PCD (CPT code E0676) provided on April 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for percutaneous transcatheter placement of
drug eluting intracoronary stent (CPT code C9600) and catheter placement in coronary artery(s) for coronary
angiography (CPT code 93458) provided on June 22, 2020.
You asked the Plan to waive the cost-sharing for the services. You say that you are appealing your cost-share
responsibility for the services you received. The Plan denied your request. The Plan says the claim was
processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received surgical services and Part B prescription drugs on June 22, 2020.
You were asked to pay a $200 copayment for the surgical services. Furthermore, you have been asked to pay
20% coinsurance of the allowed amount for prescription drugs. The allowed amount is $5,842.17. The total you
owe is $1,168.43 ($5,842.17 x 20% = $1,168.43). Your total cost share responsibility is $1,368.43 ($200 +
$1,168.43 = $1,368.43). Your 2020 EOC states that enrollees must pay a $200 copayment for a ambulatory
surgery visit and 20% of the cost for Part-B covered chemotherapy drugs and other Part-B covered drugs. 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 cost-sharing for percutaneous transcatheter placement of drug eluting
intracoronary stent (CPT code C9600) and catheter placement in coronary artery(s) for coronary angiography
(CPT code 93458) provided on June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) or pay more for the resin-based
composite (D2331) provided on October 28, 2020, and March 9, 2021.

You asked the Plan to pay for the panoramic x-ray and resin-based composite. You say that you are unable to
pay these bills. The Plan denied your request. The Plan says the panoramic x-ray is not a covered service. The
Plan also says that the resin-based composite was reprocessed for payment at the in-network rate of 50%.

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 panoramic x-ray is not among those covered under this benefit. The contract also says that you are responsible for a 50% coinsurance for resin-based composites that are rendered by an in-network provider. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) or pay more for the resin-based composite (D2331) provided on October 28, 2020, and March 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the step therapy requirements were 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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the case file does not contain documentation of trial and failure of Ruxience (Rituximab-pvvr). The documentation does not support that Ruxience (Rituximab-pvvr) would likely be less 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99214) on November 20, 2020, by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that you were called away for family matters on November 15, 2020, and had the stitches removed on Novmeber 20, 2020, by a different doctor per your provider's instructions. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they 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 office visit (CPT code 99214) on November 20, 2020, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the operative ablation of supraventricular arrhythmogenic focus or pathway with cardiopulmonary bypass represented by code 33251 provided on February 26, 2021.

You asked the Plan to pay for code 33251. You say that the medical records support the billing of code 33251. The Plan denied your request. The Plan says the medical records do not support the billing of code 33251.

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 33251 is Operative ablation of supraventricular arrhythmogenic focus or pathway (eg, Wolff-Parkinson-White, atrioventricular node re-entry), tract(s) and/or focus (foci); with cardiopulmonary bypass. 

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 code 33251. Our reviewer says that the medical records do not support the billing of code 33251. Our physician reviewer found based on the operative note, CPT 33251 -Operative ablation of supraventricular arrhythmogenic focus or pathway (eg, Wolff-Parkinson-White, atrioventricular node re-entry), tract(s) and/or focus (foci); with cardiopulmonary bypass would not be the correct billing code for the surgically performed MAZE atrial fibrillation ablation. Given the described procedure in the operative note provided, depending on the extent of the ablation and/or atrial reconstruction, and since it was done on bypass at the time of another cardiac procedure, this code is not supported and a different code would be more specific to the procedure performed. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 33251 have not been met. Therefore, we decided that the Plan does not have to pay for the operative ablation of supraventricular arrhythmogenic focus or pathway with cardiopulmonary bypass represented by code 33251 provided on February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by a provider that has opted out 
of Medicare. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the dental provider has opted out of the 
Medicare program. 
 
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 who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental 
services provided by a provider that has opted out of Medicare.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bandages provided on January 5, 2021 by an out-of-network
(OON) provider.

You asked the Plan to pay for the bandages. You say that the bandages would be cheaper through Amazon. The
Plan denied your request. The Plan says the care was obtained through an out of network provider, and
therefore is denied.

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 bandages provided on January 5, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the diagnostic laryngoscopy (CPT code 31575) 
provided on September 29, 2020. 
 
You asked the Plan to reimburse for the surgical services. You say that you are requesting reimbursement for 
the services because none of the procedures helped your medical issues. The Plan denied your request. The 
Plan says the claim was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received the diagnostic laryngoscopy (CPT code 31575) on September 29,
2020. The Medicare-allowed amount for the EKG is less than the set $75 copayment; therefore, you have been 
asked to pay the lesser amount of $151.71 for the surgical services. Your 2020 EOC states that enrollees must 
pay a $270 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, 
including but not limited to hospital or other facility charges and physician or surgical charges. 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 reimburse for the diagnostic laryngoscopy (CPT code 31575) provided on September 29, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and panoramic x-ray (D0330) provided on January 21, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation and panoramic x-ray. You say that you would like these services to be paid because you cannot have a regular x-ray done. The Plan denied your request. The Plan says the problem focused limited oral evaluation is not covered under your dental plan. The Plan also says that the panoramic x-ray has a five-year time limit before it can be redone, and this time limit has not yet passed.
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, problem focused limited oral evaluation (D0140) is not among those covered under this benefit. The contract says that panoramic x-ray (D0330) is limited to once every five calendar years. The record shows that you received a panoramic x-ray (D0330) on June 11, 2020 and your panoramic x-ray (D0330) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and panoramic x-ray (D0330) provided on January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 18, 2020.

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 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.

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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found as gene testing requires one sample and would be considered the same procedural services with one or many genes being evaluated. In this case multiple genes were tested in a panel and should be requested as one single procedure. Additionally, this testing panel does not have high quality large scale randomized studies to support it leads to improved outcomes over standard testing and treatment. Therefore, this request will be considered not reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient complete exam of visual system
(92014) and imaging of optic nerve (92133) provided on February 5, 2021, by an out-of-network (OON)
provider.

You asked the Plan to pay for the established patient complete exam of visual system and imaging of optic
nerve. You say that you would like this claim processed as a one-time courtesy exception. The Plan denied
your request. The Plan says prior authorization was not obtained for these services rendered by an OON
provider.

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 established patient complete exam of visual system (92014) and imaging of optic nerve (92133) provided on February 5, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (CPT 97110) provided to the enrollee on June 15, 2020.

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 Current Procedural Terminology (CPT) code 97110 remains not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 97110 is "therapeutic exercises to develop strength, endurance, range of motion and flexibility."

We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found a Physical Therapy Assistant is not considered a qualified healthcare provider for Current Procedural Terminology (CPT) codes. A more appropriate code from Healthcare Common Procedure Coding System (HCPCS) should be reported for services provided. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (CPT 97110) provided to the enrollee on June 15, 2020.
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 the enrollee cannot be adequately care
for in his current condition at a lower level of care. The Plan denied your request. The Plan says the enrollee
does not have clinical conditions that cannot be appropriately treated in the current hospital.

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 physician
reviewer found that the enrollee was admitted to the acute care hospital for increased seizure activity. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that is not available at the acute care hospital where he 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

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 17, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the services were 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 cardiology services at issue in this appeal. The Plan did not pre-approve
the services at issue. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for the office visit provided on September 17, 2020 by an out-ofnetwork
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 2, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 2, 2021.