Persius/hicric huggingface dataset:
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar sacral orthosis (L0648) provided on November 11, 2019.You asked the Plan to pay for the lumbar sacral orthosis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and ordering physician.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 lumbar sacral orthosis (L0648) provided on November 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly stand by assist/minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that you can barely walk, and cannot get in and out of the shower.The Plan denied your request. The Plan says you do not require oversight by a rehab physician three times a week, or an interdisciplinary approach to therapy.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that you are at minimal assist for grooming, bathing and dressing. You require moderate assist with ambulation using a rolling walker, and are at moderate assist for sit to stand. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach torehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing supervision. You may benefit and participate in additional physical and occupational therapy, but you do not require this on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Partially Favorable

We decided that the Plan has to pay for CPT code 99283. We decided that the Plan does not have to pay for CPT codes 99284 and 93010.
You asked the Plan to pay for the Emergency Room services. You say that services were medically necessary and properly billed. The Plan says that the provided records do not support the services billed.
We decided that the Plan has to pay for CPT code 99283. The services were supported in the record. We decided that the Plan does not have to pay for CPT codes 99284 and 93010. The record only supports a single Emergency Room visit and no ECG was submitted to support code 93010.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.
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 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 to the enrollee by an out-of-network provider on September 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on October 22, 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 codes 14301 and 14302 are 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 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The definition of code 14302 is adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure). We find that CPT codes 14301 and 14302 are not supported in the medical record. Specifically, the operative report does not contain documentation of an adjacent tissue transfer or arrangement of any area for 30.1 sq to 60.0 sq cm to support code 14301. Given that the primary procedure code 14301 is not supported, the add-on code 14302 is also not supported. 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 surgical services rendered on October 22, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for diagnostic nuclear testing provided by provider on October 25, 2019.You asked the Plan to waive the copayment for diagnostic nuclear testing. You say that you did not have an x-ray.The Plan denied your request. The Plan says that the correct copayment has been applied.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 enrollees must pay a $10 copayment for outpatient diagnostic tests/in-network/diagnostic procedures and tests. The Plan says you must pay a $35 copayment for diagnostic nuclear testing.Based on the Plan contract, however, you cannot be asked to pay more than a $10 copayment for diagnostic nuclear testing.Therefore, we decided that the Plan has to waive the copayment for diagnostic nuclear testing provided by provider on October 25, 2019.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: Drugs
Decision: Unfavorable

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

We decided that the Plan does not have to pay for hospital discharge day management service provided by physician on August 17, 2019.You asked the Plan to pay for hospital discharge day management. You say that you are appealing with additional medical records.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not support the procedure code billed on this claim.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 99239 is hospital discharge day management, more than 30 minutes.We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation does not support that this service was more than 30 minutes in duration. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management have not been met.Therefore, we decided that the Plan does not have to pay for hospital discharge day management service provided by physician on August 17, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for emergency room visits provided on November 7, 2019 and November 16, 2019.
You asked the Plan to waive the copayments for emergency room visits. You say that these trips to the emergency room could have been prevented if your doctor had submitted a referral for treatment in a timely manner. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.
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 $90 copayment for each emergency room visit. There were 2 emergency room visits, resulting in a total copayment obligation of $180. You have been asked to pay $90 copayment for each emergency room visit. Emergency room visits fall within the Emergency Care 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 copayments for emergency room visits provided on November 7, 2019 and November 16, 2019.
Please note that this decision is only in regards to the emergency room copayments you are being charged. Please contact the Plan for more information about any other appeals you may have made.
Your complaint regarding your experience with your treating physician is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 2) provided on October 7, 2019.
You asked the Plan to pay for the gingival irrigation. You say that you were under the impression that the provider was in network and the services would be covered. The Plan denied your request. The Plan says gingival irrigation is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, gingival irrigation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921 x 2) provided on October 7, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to hold you harmless fora Computed Tomography (CT) scan with contrast material providedon November 20, 2019.You asked the Plan to hold you harmless forCT scan with contrast material. You say that you cannot afford to pay for this.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this CT scan was not medically necessary.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. the plan follows these rules.You were referred for CT scan with contrast material bya contract provider. The file does not show that the plan provided notice that CT scan with contrast material would not be covered. Under Medicare rules, this means CT scan with contrast material is considered approved by the plan .Therefore, we decided that the Plan has to hold you harmless fora Computed Tomography (CT) scan with contrast material provided on November 20, 2019.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 pay for mesh removal (11008) provided on September 9, 2019.You asked the Plan to pay for the mesh removal. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 11008 was billed without an appropriate primary procedure code.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 the mesh removal is a type I add-on code. This means that this code has a limited number of identified primary procedure codesand is only eligible for payment if one of the listed primary codes is also eligible for payment. CPT code 11008 has not been billed with an appropriate primary code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, wedecided that the Plan does not have to pay for mesh removal (11008) provided on September 9, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on September 26, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal wasrequested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on September 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core build-up.You asked the Plan to pre-approve the core build-up. You say that decay is present and restoration is needed.The Plan denied your request. The Plan says this 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 Plan does not have to pre-approve the core build-up.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eye exam (92014) refraction (92015) provided on October 17, 2019.
You asked the Plan to pay for the vision services. You say that it was prudent for you to seek professional help in determining the level of damage to your eyes and what might be done about it. The Plan denied your request. The Plan says the benefits have been exhausted.
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 records show that you received an eye exam and vision test on March 12, 2019 and April 2, 2019, therefore the benefit has been exhausted for the 2019 year. 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 at this time. Therefore, we decided that the Plan does not have to pay for eye exam (92014) refraction (92015) provided on October 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on September 25, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on September 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9501) provided on October 2, 2019 through October 8, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code S9501 has a status code of I which is not valid for Medicare purposes.
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 S9501 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, CPT code S9501 has a status code of I. This means that CPT code S9501 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9501) provided on October 2, 2019 through October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lumbar-sacral orthosis (L0648).
You asked the Plan to pre-approve Lumbar-sacral orthosis. You say that you would like to appeal because this brace will help the enrollee. The Plan denied your request. The Plan says this enrollee does not meet the Medicare criteria.
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 Lumbar-sacral orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not support the need for a lumbar brace. The enrollee has degenerative back pain. A brace is not needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve Lumbar-sacral orthosis (L0648).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3.
You asked the Plan to pre-approve the Gelysyn-3. You say that the Gelsyn-3 is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.
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 Gelysyn-3. Our reviewer says that the member has not tried and failed a trial of Monovisc. Our physician reviewer found Monovisc is not likely to be less effective or have adverse effects for the member.
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 Gelysyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3.