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

We decided that the Plan does not have to pre-approve an office visit (99213) to be rendered by the out of network (OON) provider.

You asked the Plan to pre-approv ethis service. You say that you are requesting a reconsideration of the Plan's denial as you have been seeing this provider for fifteen years.The Plan denied your request. The Plan says as a member of the Plan you must obtain services from an in-network provider, who is certified by Medicare.

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. Additionally, no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service.Additionally, the provider does not participate in the Medicare program. Therefore, we decided that the Plan does not have to pre-approve an office visit (99213) to be rendered by the out of network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve40 Mg Esomeprazole Magnesium Capsules.

You asked the Plan to pre-approve the Esomeprazole Magnesium. You say that you would like reconsideration because this drug is medically necessary.The Plan denied your request. The Plan says this drug is not covered for the member's condition under Medicare Part B.

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-approve40 Mg Esomeprazole Magnesium Capsules.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe contact lenses provided on August 5, 2020.You asked the Plan to pay forthe contact lenses. You say that your supply of contacts runs out in one year.The Plan denied your request. The Plan says the contact lenses exceed the maximum benefit per period.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The documentation shows that you last received contact lenses on July 17, 2019. Your plan only covers contact lenses once every 2 years.Based on this information, we decided that the Plan's rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay forthe contact lenses provided on August 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forhearing aids (V5261) provided on August 5, 2020.You asked the Plan to pay forhearing aids. You say that you were unaware you were required to purchase your hearing aids through the Plan.The Plan denied your request. The Plan says the hearing benefit is not covered if the services are not registered in advancedMedicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered through the Plan. We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Specifically, you did not order your hearing aids through the Plan.Therefore, we decided that the Plan does not have to pay forhearing aids (V5261) provided on August 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveeight (8) additional routine transportation trips.You asked the Planto pre-approveadditional routine transportation trips. You say that you have medical visits you need transportation to get to.The Plan denied your request. The Plan says that your request exceeds the benefit limit.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of twelve (12) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan does not have to cover routine transportation above benefit maximum of twelveroutine transportationtrips.Therefore, we decided that thePlan does not have to pre-approveeight (8) additional routine transportation trips
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approveVimpat.You asked the Plan to pre-approveVimpat. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested drug is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Vimpat. Our reviewer says that the documentation does support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has unspecified neurologic disorder, possibly autoimmune, and with seizure disorder, with daytime hypersomnolence. The documentation supports a very complex enrollee with complex diagnosis and complex symptomatology. It is medically reasonable to changeto Vimpat as the Keppra may be causing symptoms that may be affecting diagnosis and treatment of the underlying condition. Therefore, the enrollee meets criteria for the requested drug.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vimpat have been met.Therefore, we decided that the Plan has to pre-approveVimpat.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimular electrode array for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there are no covered conditions/diagnoses for the requested procedure.
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 the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the medical records provided for review did not indicate that the enrollee has any of the indications/conditions for which the requested service is covered. There is no note of a nerve root injury. The enrollee has not previously undergone surgery (that would result in a diagnosis of post-surgical or post-traumatic including that of post-laminectomy syndrome). In as much the requirements for coverage of a SCS would not be met. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimular electrode array for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveexcision of excessive skin tissue.You asked the Planto pre-approvethe procedure. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested procedure is considered cosmetic in nature.The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.  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 procedure. Our reviewer says that the requested procedure is not medically reasonable or necessary. Our reviewer found there is a suggestion of functional impairment related to skin irritation.  However, there was insufficient documentation to support that she had failed conservative dermatologic management. In addition, photographs were not provided to assess the severity of her condition, as the examination detail did not adequately document the degree of soft tissue excess of the arms or upper lateral flanks. Thus, without clear detail of the severity of the condition and adequate documentation of any failed conservative management, the requested procedures do not satisfy the above guidelines.
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 procedure have not been met.Therefore, we decided that the Plandoes not haveto pre-approveexcision of excessive skin tissue.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthis service. You asked the Plan to pay forlab services provided to the enrollee. You say that this claim should be paid.The Plan denied your request. The Plan says the records do not contain documentation to support the coding criteria for code G0483 billed on date of service May 14, 2020. The documentation does not support 22 or more drug classes.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 records provided do not support the services billed. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay fordrug testing provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided to the enrollee on May 29, 2020.You asked the Plan to pay forthis testing. You say that this claim should be paid.The Plan denied your request. The Plan says the medical records indicate that drug test(s), definitive for 8 -14 drug classes was performed; there is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code, G0481, that should be used.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 claim submitted cannot be paid as billed due to a coding error. Medicare rules for coverage of this testing have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing provided to the enrollee on May 29, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dayvigo 5mg tablet.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs.
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 Dayvigo 5mg tablet.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe home infusion administrative services provided on May 21, 2020 billed with code S9328.You asked the Planto pay forthe home infusion administrative services. You say that these services were medically necessary and should be paid.The Plandenied your request. The Plansaysthe code used is not valid for Medicare.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S9328 has a status indicator of "I" in the Physician Fee Schedule. This means that it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion administrative services have not been met.Therefore, we decided that the Plandoes not haveto pay forthe home infusion administrative services provided on May 21, 2020 billed with code S9328.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveOxycontin tab 15mg CR for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe plan benefits say this medication falls under Part D coverage, but the enrollee has no Part D pharmacy 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 Plandoes not haveto pre-approveOxycontin tab 15mg CR for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveocclusal guard -soft appliance, full arch (D9945).You asked the Plan to pre-approvethe dental services. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says the service is not a covered benefit under the plan.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. This service is not listed in the member's manual as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pre-approveocclusal guard -soft appliance, full arch (D9945).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee
from February 12, 2020, to March 11, 2020.
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Maximus overturned the Plans denial because a 2020 Evidence of Coverage had not been submitted. The Plan
submitted the 2020 Evidence of Coverage and requested a reopen.
The Plan is correct in this case. 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 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 out of network physician services provided to the enrollee from February 12, 2020, to March 11, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pay fornursing services provided to the enrollee on November 25, 2019. You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the billing provider is not eligible to be paid for this service. We overturned the Plans denial stating the NPI was valid. The Plan requested a reopen and stated that the provider was not eligible for payment of this service. The Plan says that the NPI Registry websiteshows this provider is registered with  a specific taxonomyas a Nurse Practitioner. The Plan says that the provider did not bill with the providersregistered taxonomy. The Plan included the claim showing the provider billed as a Registered Nurse (RN) taxonomyand not as a Nurse Practitioner (NP). 
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say providers must bill the appropriate Medicare eligibility for services. In this case the correct taxonomy was not billed on the claim. A stated above, a Registered Nurse is not an eligible Medicare provider. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay fornursing services provided to the enrollee on November 25, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on June 22, 2020.
You asked the Plan to pay for the knee orthosis (L1833-LT) and suspension sleeve (L2397-LT). You say that
the orthoses were medically necessary. The Plan denied your request. The Plan says the orthoses are not
supported in the medical records received.
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 orthosis (L1833-LT) and
suspension sleeve (L2397-LT). Our reviewer says that the orthoses were not medically necessary. Our
physician reviewer found the enrollee's chief complaint was knee pain, as well as back pain and shoulder pain.
The documentation in the case file does not support that the requested knee orthosis and sleeve were medically
reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the
LCD. There is insufficient credible documentation of an examination of the enrollee, and there is insufficient
credible objective documentation of joint laxity.
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 orthosis (L1833-LT) and suspension sleeve (L2397-LT) have not been
met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve
provided on June 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the catheter placement and laboratory test
provided on July 17, 2020.
You asked the Plan to waive the copayment for the catheter placement and laboratory test. You say that you
have never received a bill for this much before. You say that you were overcharged because you normally pay
a fee of $70 or $80. The Plan denied your request. The Plan says the copayments applied correctly.
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 $325 for
each Medicare-covered, in-network, outpatient hospital facility visit, and $10 per day, per in-network provider,
for Medicare-covered lab services.
You have been asked to pay a $325 copayment for the catheter placement and $7.86, which is less than the
standard $10 copayment for the laboratory test. The catheter placement falls within the "Outpatient surgery
including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category.
The laboratory test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for the catheter placement and laboratory test provided on July 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on 
March 6, 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 enrollee did not have prior authorization for out of network care. 
 
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 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 out of network lab services 
provided to the enrollee on March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
no documentation of prior imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that lumbar epidural steroid injections are only 
covered under certain medical indications.  
 
We looked at the file and Medicare rules. The documentation provided does not include plain films or 
advanced imaging. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a periodontal scaling and root planing of one to three 
teeth per quadrant (D4342). 
 
You asked the Plan to pre-approve the scaling and planing. The Plan denied your request. The Plan says this 
service is not covered under the enrollee's benefit plan. 
 
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 pre-approve a 
periodontal scaling and root planing of one to three teeth per quadrant (D4342).