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

We decided that the Plan does not have to pay for the services rendered on August 29, 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 procedure code 0482T is 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 0482T is absolute quantitation of myocardial blood flow, positron emission tomography (PET), rest and stress (List separately in addition to code for primary procedure).We find that CPT code 0482T is not supported in the medical record. Specifically, there are no records for the date of service at issue to support the use of code 0482T. 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 services rendered on August 29, 2019. The Plan references Local Coverage Determination (LCD) L35490 in their determination; however, this is not valid for the Part B jurisdiction and was not used in the MAXIMUS determination.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you did not call for the ambulance. You say that you had gotten dizzy and someone else called the ambulance. The responders came and took your vitals however you advised them that you did not need transportation. You say that you should not be held responsible for the ambulance because no one asked you if you wanted it called. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 22, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular junction testing coded 95937 provided on May 9, 2019.
You asked the Plan to pay for the neuromuscular junction testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not supported by the documentation.
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 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. We find that CPT code 95937 is not supported in the medical record. Specifically, the documentation submitted did not support neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method. The documentation shows that train of four testing/monitoring was performed which does not meet guidelines of CPT 95937. Therefore, it is inappropriate to bill the code for neuromuscular junction testing for train of four monitoring. Based on this information, we decided that Medicare rules for coverage of the neuromuscular junction testing have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular junction testing coded 95937 provided on May 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient lab work provided on September 20, 2019.
You asked the Plan to waive the copayment for outpatient lab work. You say that you would like this amount
refunded. The Plan denied your request. The Plan says the correct copayment has been 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 $40
copayment for outpatient diagnostic tests/lab services/outpatient hospital.
You have been asked to pay $38.66 which is less than your copayment amount of $40 for outpatient lab work.
Since outpatient lab work was provided in an outpatient hospital setting, the correct copayment has been
applied. Outpatient lab work falls within the outpatient diagnostic tests/lab services/outpatient hospital 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 outpatient lab work provided on September 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower denture (D5120).You asked the Plan to pre-approve a complete lower denture. You say that the item is necessary since youare unable to eat and are having difficulty talking.The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria has not been met.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. The Plan covers a complete lower denture once every five years. The record shows that you received a lower denture on September 4, 2019. This means that you are not eligible for health plan coverage of a complete lower denture at this time.We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a complete lower denture have notbeen met.Therefore, we decided that the Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 12, 2018 by an out of network (OON) provider.You asked the Plan to pay for office services. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the enrollee self-directed for service.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 for the medical services provided on March 12, 2018 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT of the head or brain, chest x-ray, CT of maxillofacial area, CT cervical spine provided on July 30, 2019.
You asked the Plan to pay for the CT scans and chest x-ray. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the CT of the head or brain, chest x-ray, CT of maxillofacial area, CT cervical spine provided on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on September 12, 2019.
You asked the Plan to waive the deductible for the office visit. You say that you were told the by the provider's office that the doctor was in-network. You would like the claim to be paid with the in-network benefit. 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. Your contract with the Plan says that there is a $1,000 deductible that applies towards out-of-network office visits. The office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that applies towards out-of-network office visits. The record shows the provider is out-of-network. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on September 12, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on September 12, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for definitive drug testing (G0482) provided to the enrollee.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization and no medical records were submitted to show this testing was medically necessary or met the Medicare coverage criteria for this type of testing.
The Plan must follow Medicare rules. Medicare rules say that plans can require enrollees to get care from network providers. Medicare has specific coverage criteria for definitive drug testing. The contract with the Plan says that the Plan must 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. The Plan did not pre-approve this testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for definitive drug testing (G0482) provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin based composite for 4 or more surfaces on a posterior tooth (D2394) provided on October 10, 2019.You asked the Plan to pay for the dental service. You say that you called before your appointment to check on your coverage. You say that you should be able to do your fillings as you had not used your $2,000 annual benefit.The Plan denied your request. The Plan says 2 fillings per calendar year are covered. The Plan also says that the frequency limit has been exceeded.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 and fillings are a covered service, the  frequency limit of 2 per calendar year has been exceeded. The Plan previously paid for 2 fillings that you received on March 27, 2019. Additionally, the record shows that you did make a coverage inquiry with the Plan, but it was specifically for crowns and your annual maximum and not fillings. Therefore, we decided that the Plan does not have to pay for the resin based composite for 4 or more surfaces on a posterior tooth (D2394) provided on October 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for cervical, multiple post collar, occipital/mandibular supports (L0180) provided on May 6, 2019.
You asked the Plan to pay for the orthosis. You say that the only difference with the delivery ticket would be the addition of the in-house shipping ticket that the enrollee is sent with the equipment. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. The rules state the contractor shall verify that the face-to-face encounter documentation includes information supporting that the beneficiary was evaluated or treated for a condition that supports the DIVIE item(s) ordered. If this information is not included, the contractor shall deny the claim. If the physician completed the written order before the face-to-face encounter, the contractor shall deny the claim. There is no claim in enrollee history from the prescribing provider on the date of service or in the last 6 months prior to the date of the services. There is no delivery confirmation document or documentation in the exam notes validating the enrollee received the device or supplies. There is no document from the DME supplier to indicate what device or supplies were delivered or given to the enrollee.
Therefore, we decided that the Plan does not have to pay for cervical, multiple post collar, occipital/mandibular supports (L0180) provided on May 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had on June 30, 2019.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the copayment.
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 copayment for each primary care doctor visit. Review of the file shows that you had a PCP visit on June 30, 2019. You have been asked to pay a $20 copayment for the visit. The visit falls within the physician 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 waive the copayment for the office visit you had on June 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forpathology services provided on August 12, 2019 by an out of network (OON) provider.You asked the Plan to pay forpathology services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 forpathology services provided on August 12, 2019by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo (Nivolumab).You asked the Plan to pre-approve Opdivo. The Plan denied your request. The Plan says the use of Nivolumab as monotherapy for stage III metastatic non-small cell lung cancer is not supported.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Opdivo. Our physician reviewer found that the enrollee has stage IIIB non-small cell lung cancer. The requested use of Nivolumab is not FDA-approved for the enrollee's diagnosis. The use is not listed as, not indicated, not supported, or not recommended in any of the compendia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met.Therefore, we decided that the Plan does not have to pre-approveOpdivo (Nivolumab).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a left custom foot orthosis (L3000-LT) and a right custom foot orthosis (L3000-RT).
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says that your condition doesn't meet the rules for approval because your medical record shows that you are not diabetic and do not wear a shoe with an attached brace.
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. The in-network provider billed this with the KX modifier indicating that this is for use with a shoe integral to a brace. The Plan did not forward any medical records to contradict this. As such, we find that the documentation as submitted does not substantiate denial of payment in this case. Therefore, we decided that the Plan has to pay for a left custom foot orthosis (L3000-LT) and a right custom foot orthosis (L3000-RT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthoses provided on August 6, 2019.
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthoses (L3960). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the records do not support medical necessity.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. There is no itemized delivery ticket to indicate what specific supplies were provided. Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthoses provided on August 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient lab tests provided on September 20, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient lab tests. You say that these services were medically necessary for the patient's current prospective neuropsychiatric treatments.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.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 foroutpatient lab tests provided on September 20, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on June 7, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on June 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography (CT) of the head (70450) provided June 10, 2019.
You asked the Plan to pay for the radiology services. You say that the claim was correctly submitted and should be paid. The Plan denied your request. The Plan says the code at issue shares a bundled relationship with a code already paid.
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, we have confirmed that code 70450 has a bundled relationship with code 70460 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for Computed Tomography (CT) of the head (70450) provided June 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered to the enrollee on October 3, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered to the enrollee on October 3, 2019.