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

We decided that the Plan does not have to pay forthe physician services provided on June 14, 2019.You asked the Plan to pay forthe physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the claim was not filed timely per Medicare guidelines.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 the physician services was not filed until September 14, 2020. 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 forthe physician services provided on June 14, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 16, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.

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 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 medical services provided on July 16, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on July 28, 2020.You asked the Plan to waive the copayment forthe office visit. You say that you would like the claim reprocessed as in-network. 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 $15 copayment for provider and professional services at an in-or out-of-network PCP's office. You have been asked to pay a $15 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the provider is out-of-network.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 copaymentforthe office visit provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 medical services provided on July 15, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that the pain in your foot is affecting your quality of life.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show thatyou do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFarxiga tablets.You asked the Plan to pre-approveself-administered drug. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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-approveFarxiga tablets.Benefits for self-administered drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided on April 15, 2020.You asked the Plan to pay forthe physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services arenot covered.The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. In this case,the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment.Therefore, we decided that the Plan does not have to pay forthe physician services provided on April 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompounded hydromorphone powder, sodium chloride injection and sterile water injection.You asked the Plan to pre-approvethe requested compound drug. You say that the enrollee has had an intrathecal pump for years. You say that it is very important for the enrollee to continue therapy and get the medication needed.The Plan denied your request. The Plan says the enrollee does not have any Part D coverage under this contract.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part Bcoverage.Therefore, we decided that the Plan does not have to pre-approvecompounded hydromorphone powder, sodium chloride injection and sterile water injection.Benefits for the requested compound drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoutpatient physical therapy services to be performed by a chiropractor.You asked the Plan to pre-approvephysical therapy. You say that you are appealing the Plan's denial.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this service is not covered when performed by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pre-approveoutpatient physical therapy services to be performed by a chiropractor
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on October 6, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that this procedure was medically necessary and you should not have to pay for this follow-up colonoscopy. 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 $275 copayment per visit, per provider, per day for surgery performed in an outpatient hospital setting. You have been asked to pay $275 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the colonoscopy was completed due to an abnormal stool test and a polyp which makes the colonoscopy diagnostic in nature.
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 colonoscopy provided on October 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wound care services provided on May 20, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe wound care services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 forthe wound care services provided on May 20, 2020 by an out of network (OON) provider
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pre-approvea wireless capsule endoscopy (WCE) for the enrollee.You asked the Plan to pre-approvethis service. You say that this procedure is medically necessary.The Plan denied your request. The Plan says because the enrollee has a pacemaker, the Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct LCD criteria.The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that contraindications to WCE include presence of a cardiac pacemaker. The enrollee has a pacemaker. This service would not be covered by Medicare in this instance. Therefore, we decided that the Plan does not have to pre-approvea wireless capsule endoscopy (WCE) for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay forthe interpretation of a knee x-ray (up to 2 views) provided on June 4, 2020. You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan states that this claim denied because the Plan had previously paid for this service. The Plan statesthe NPI website shows that both billing providers are of the same practice group. The Plan says that the correct billing of this service needed to include modifier 59,which is used to distinguisha separate and distinct service from those that were previously paid. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group,only one service may be reported unless the services are for unrelated problemsand/or are reported as a separate and distinct service. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met.Therefore, we decided that the Plan does not have to pay forthe interpretation of a knee x-ray (up to 2 views) provided on June 4, 2020
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay for positron emission tomography (PET) scan provided to the
enrollee on February 6, 2020 and billed under code 78815-26-PS.
You asked the Plan to pay for this imaging. You say that this service should be covered by the Plan. The Plan
denied your request. The Plan says Medicare billing criteria were not met. We overturned the Plans
denial stating the PET scan was medically necessary. The Plan requested a reopen and stated that the issue was
not medical necessity but that the claim was submitted with inappropriate codes. The Plan says that the claim
billed with diagnosis code C18.9 for Malignant neoplasm of colon. The diagnosis is inconsistent with the
procedure. The Plan states an appropriate diagnosis for the procedure was not billed as required by Medicare.
The Medicare guidelines state that claims for PET scan services must be billed using the ASC X12 837
professional claim format or on Form-CMS 1500 with the appropriate HCPCS or CPT code and diagnosis
codes to the A/B MAC (B). The Plan further states the National Coverage Determination (NCD) for Positron
Emission Tomography (FDG) for Oncologic Conditions (220.6.17), shows that diagnosis code C18.9 is not
listed as an appropriate diagnosis code. Based on this CMS guidance, claims must be billed with an appropriate
CPT and diagnosis code, which this claim was not, therefore, Medicare billing criteria are not met.
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, this claim
cannot be paid as billed and was denied administratively due to an error with the diagnosis code reported.
Therefore, we decided that the Plan does not have to pay for positron emission tomography (PET) scan
provided to the enrollee on February 6, 2020 and billed with code 78815-26-PS.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pay fornursing facility care (99304, 3288F, G8483, 1123F) provided on March 18, 2020. You asked the Plan to pay forthis claim as billed. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that this claim 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 Nurse Practitioner under.  However, the taxonomy on the website and the taxonomysubmitted on the claim are two different numbers. The Plan submitted the additional pages of the claim image that shows the provider has billed with a Registered Nurse taxonomy, which is contrary to what is stated on the NP website. The provided billed as a RegisteredNurse, wound care. This taxonomyis not eligible to receive Medicare reimbursement. 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 provider codes. In this case the provider has billed with an ineligible taxonomy code for Medicare payment. Therefore, we decided that the Plan does not have to pay fornursing facility care (99304, 3288F, G8483, 1123F) provided on March 18, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home sleep study.

You asked the Plan to pre-approve the home sleep study. You say that the records provided support the need for the requested services.The Plan denied your request. The Plan says the enrollee has significant comorbidities and does not meet the criteria for a home sleep study.

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 home sleep study. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records provided do not contain any information that would support the possible diagnosis of sleep apnea. Common signs and symptoms were not mentioned in review of symptoms or in office notes enclosed.

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 home sleep study have not been met.Therefore, we decided that the Plan does not have to pre-approve a home sleep study.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveintra-dialytic parenteral nutritional supplements.You asked the Plan to pre-approvenutritional supplements. You say that multiple attempts at standard forms of nutrition therapy were trialed, but the enrollee's nutritional status needs more aggressive nutrition support.The Plan denied your request. The Plan says the denial of authorization is correct, because the enrollee's gastrointestinal tract is functioning.The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.The items you asked the Plan to pre-approve are nutritional supplements.Therefore, we decided that the Plan does not have to pre-approveintra-dialytic parenteral nutritional supplements.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the physician/facility failed to obtain authorization. The Plan denied your request. The Plan says prior authorization was not obtained.
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 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 medical services provided on September 3, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinsertion of an interspinous spacer device (Vertiflex).You asked the Plan to pre-approveVertiflex. You say that this treatment is considered safe and effective and is supported by strong clinical evidence.The Plan denied your request. The Plan says the denial of authorization forthis service is correct, because Vertiflex is considered experimental/investigational.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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental, more research is needed to show safety and efficacy of the interspinous process 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 Vertiflex have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of an interspinous spacer device (Vertiflex)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe non-covered chiropractic services provided from September 8, 2020 to October 14, 2020.You asked the Plan to pay forthe non-covered chiropractic services. You say that you would like the Plan to reconsider their denial of payment.The Plan deniedyour request. The Plan says the services are not covered when provided by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue, CPT codes S9090 and 99212 are not manual manipulation of the spine. These services are not covered when provided by a chiropractor.Therefore, we decided that the Plan does not have to pay forthe non-covered chiropractic services provided from September 8, 2020 to October 14, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordental services (D0140, D0220 and D1999) received on September 15, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis is not a covered 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pay fordental services (D0140, D0220 and D1999) received on September 15, 2020