Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 physician services provided on November 30, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).
You asked the Plan to pre-approve Euflexxa. You say that the enrollee needs this medication. The Plan denied
your request. The Plan says the enrollee has not tried and failed the preferred viscosupplements, Monovisc and
Orthovisc.
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 Euflexxa. Our reviewer says that
Euflexxa is not medically necessary. Our physician reviewer found the provided documentation does not
indicate that the enrollee has tried and failed the required drugs. The reviewer found that there is no
documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely
have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve Euflexxa (J7323).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (72170) provided on July 8, 2020.
You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this code is bundled into a previously paid procedure.
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 72170 has a bundled relationship with code 73501, which was billed by a physician in the same group practice and specialty, 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 an x-ray (72170) provided on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) for tooth # 3 provided on December 16, 2020.

You asked the Plan to pay for the dental service. You say that the service was denied because it was used as a stand-alone filling. You say that tooth # 3 has a crown. You say that the crown was loose. You also that the core build up was needed to retain the crown. The Plan denied your request. The Plan says core build up is only covered when performed with a crown. The Plan says that there was no crown performed with this core build up. The Plan also says that it is not covered in this situation.

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 core build up is listed as a covered service, the core build up that is performed without a crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) for tooth # 3 provided on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain pump analysis rendered on December 11, 2020.

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 were billed incorrectly.

The plan must follow Medicare rules. The rules say that anatomical modifiers are required for procedures performed on different anatomical sites.

We looked at the file and Medicare rules. The provider billed procedure code 62370 with the -RT modifier. An anatomical modifier is not appropriate for this procedure code. Therefore, we decided that the Plan does not have to pay for the pain pump analysis rendered on December 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean annual health club membership (S9970).You asked the Plan to pre-approvean annual health club membership. You say that an exercise program would be beneficial.The Plan denied your request. The Plan says the service at issue is not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The services at issue in this appeal are gym benefits.The Plan does not cover health club memberships. Therefore, we decided that the Plan does not have to pre-approvean annual health club membership (S9970).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 12, 2020.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery provided on January 12, 2021 and February 2, 2021.

You asked the Plan to waive the copayment for the cataract surgeries. You say that you were never told you had a $250 copayment for the surgery. 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 a $0 or $250 copayment for each Medicare-covered ambulatory surgical center visit. $0 copayment for any surgical procedures (i.e., polyp removal) during a colorectal screening and a $250 copayment for all other Ambulatory Surgical Center (ASC) services. 

You have been asked to pay a $250 copayment for each cataract surgery. The total amount you owe is $500 ($250/surgery x 2 surgeries = $500). The cataract surgeries fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 cataract surgery provided on January 12, 2021 and February 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on May 26, 2020.
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that until this year it has been billed as preventive. You say that you have never had to pay for a diagnostic mammogram before. The Plan denied your request. The Plan says the copayment 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 a $100 copayment for each Medicare-covered diagnostic procedure and test in an in-network outpatient hospital facility.
You have been asked to pay a $100 copayment for the diagnostic mammogram. The diagnostic mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show a diagnostic mammogram was performed. 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 diagnostic mammogram provided on May 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G orthotic device.
You asked the Plan to pre-approve orthotic device. You say that the requested brace effectively replaces the
enrollee's elbow and hand function so he can regain function. The Plan denied your request. The Plan says the
denial of authorization for this device is correct, because studies have not proven that this device is helpful for
the treatment of the enrollee's condition.
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 orthotic device. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards,
and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use
based on scientific evidence. There is insufficient evidence in the literature that the MyoPro orthosis will
improve the long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long-term
use.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of orthotic device have not been met. Therefore, we decided that the Plan does not
have to pre-approve a MyoPro 2 Motion G orthotic device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on January 26, 2021 by an out of network (OON) provider.

You asked the Plan to pay for outpatient hospital services. You say that these services were medically necessary. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 outpatient hospital services provided on January 26, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) and to pay more for the comprehensive oral evaluation (D0150), prophylaxis (D1110), and topical application of fluoride varnish (D1206) provided on January 4, 2021 by an OON provider.
You asked the Plan to pay for the preventive procedure or pay more for the comprehensive oral evaluation, prophylaxis, and topical application of fluoride varnish. You say that you were told that this was a participating provider. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that the preventive procedure 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, unspecified preventive procedure (D1999) is not among those covered under this benefit. The contract also says that you may be billed more if you receive services from an OON provider. Therefore, we decided that the Plan does not have to pay for the preventive procedure (D1999) and to pay more for the comprehensive oral evaluation (D0150), prophylaxis (D1110), and topical application of fluoride varnish (D1206) provided on January 4, 2021 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a LINX device.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the safety of the LINX device has not been assessed in patients with Barrett's esophagus, nor is LINX device function likely to be optimal with impaired esophageal peristalsis. The records show that the enrollee has normal lower esophageal function that does not warrant surgical augmentation. The services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a LINX device.
Local Coverage Article (LCA) A56389 referenced by the Plan is not valid for the state of Montana and was not used in the MAXIMUS determination.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from October 28, 2020, to November 1, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $185 copayment per day, for days 1-7 for each Medicare-covered hospital stay. You have been asked to pay a $185 copayment for each day the inpatient hospital stay. ($185 x 4 days = $740). The inpatient hospital stay falls within the "Inpatient hospital 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 copayment for the inpatient hospital stay provided from October 28, 2020, to November 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient radiation services provided on November 2, 2020 to December 3, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe outpatient services. You say that the provider accepted Medicare and the Plan is to cover the 20% that Medicare does cover. You do not understand why the Plan is refusing to cover your lung cancer treatment.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. If the Plan does not cover services received from an out of network provider, the services will be covered by Original Medicare if they are Medicare covered 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 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 outpatient radiation services provided on November 2, 2020 to December 3, 2020 by an out of network (OON)provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on October 30, 2020.
You asked the Plan to pay for the home visit. You say that the physician depends on the hospital staff to verify eligibility and obtain the proper authorization. You say that the physician provided medically necessary services and is seeking reimbursement. 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 requested provider in this case is not a network provider with the Plan. 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 home visit provided by an out-of-network provider on October 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307 and G0481) provided on June 8, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory but the submitted medical documentation indicates the specimen was obtained in an office setting.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the claim was submitted with a laboratory place of service code, but the documentation suggests the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (80307 and G0481) provided on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for manual therapy techniques (97140) outpatient office visit (99213) chiropractic manipulative treatment (98943) provided October 1, 2020 to January 7, 2021
You asked the Plan to pay for the chiropractic services. You say that you want to appeal the denial of payment of medical services provided for your physical and mental welfare to have a chiropractor of your choice. The Plan denied your request. The Plan says these services are not covered under the plan benefits.
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 pay for manual therapy techniques (97140) outpatient office visit (99213) chiropractic manipulative treatment (98943) provided October 1, 2020 to January 7, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 17, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid.
The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care
physician.
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 physician services provided on December 17,
2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 7, 2020.
You asked the Plan to pay for the ambulance services. You say that you fell in your home and the medics assisted you back up. 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 November 7, 2020. 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 provided on November 7, 2020.