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

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on August 30, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the records do not contain documentation to support the coding criteria.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 80307 is "Presumptive Drug Class Screening" and the definition of HCPCS G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed."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 services. Our reviewer says that the services at issue in this case were not coded correctly, or supported by the medical records. Our physician reviewer found on 8/30/2019, the provider documented that a UDS was to be performed. A UDS form has been submitted for review, but the form does not include any test results. Records then indicate that a UDT was ordered. The results of a UDT are not submitted for review. The documentation does not support that a UDT was medically necessary, reasonable or performed.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 services have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on August 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gingival irrigation (D4921 x 4) provided on September 19, 2019.You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says this service is not approved for coverage.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.You do not meet the conditions for approval of gingival irrigation (D4921 x 4).Therefore, we decided that the Plan does not have to pay for gingival irrigation (D4921 x 4) provided on September 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Orencia.You asked the Plan to pre-approve the Orencia. You say that the enrollee has been on multiple biologics in the past including Rituxan and Actemra. You also say that the enrollee's symptoms have responded well to Orencia subcutaneous samples.The Plan denied your request. The Plan says Medicare's drug reference books (compendia) and coverage determinations (when relevant), do not support using this drug to treat inflammatory polyarthropathy and undifferentiated connective tissues disease.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Orencia. Our reviewer says that the Orencia is not medically necessary. Our physician reviewer found this appeal considers the requested Orencia injection for the treatment of inflammatory polyarthropathy and undifferentiated connective tissue disease. The submitted documentation, Medicare guidelines, and Medicare approved compendia were considered. Our reviewer found that the review of approved compendia does not support the treatment of the enrollee's diagnoses with the treatment of Orencia. Without the support of the documentation, medical necessity cannot be determined.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 Orencia have not been met.Therefore, we decided that the Plan does not have to pre-approve the Orencia.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on December 12, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 71045 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 71045 and 32555. Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 32555. Code 71045 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on December 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) and prophylaxis (D1110) provided on December 9, 2019.You asked the Plan to pay forthe dental services. You say that the holidays were approaching. You say that the dental office would be closed during the 6 month date span for an exam and cleaning.The Plan denied your request. The Plan says 1 oral exam and 1 cleaning are covered every 6 months. The Plan also says the frequency limit for these services has been exceeded.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage and the oral exam and prophylaxis are listed as covered services, the frequency limit of once every 6 months has been exceeded. The record shows that you received these services on June 24, 2019.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) and prophylaxis (D1110) provided on December 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered to you on October 18, 2019.
You asked the Plan to waive the copayment for these services. You say that the plan should cover the copayments. The Plan denied your request. The Plan says the copayment was 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 $10 copayment per visit for laboratory tests.
Review of the file shows that you received laboratory services on October 18, 2019. You have been asked to pay a $10 copayment for these services. These services fall within the laboratory tests 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 laboratory services rendered to you on October 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe supplies provided to the enrollee during ambulance transport on October 14, 2019.You asked the Plan to payforthe supplies. The Plan denied your request. The Plan says payment is included in the ambulance charge.The Plan must follow Medicare rules. Medicare rules say that payment for ambulance supplies is included in the payment for the transport. We looked at the file and Medicare rules. Payment for the supplies provided to the enrollee during ambulance transport is included in the payment for the transport. Separate payment cannot be made for these supplies. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met.Therefore, we decided that the Plan does not have to pay forthe supplies provided to the enrollee during ambulance transport on October 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan provided on October 17, 2019.You asked the Plan to waive the copayment fora CT scan. You say that you were not informed that you would owe a copayment.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $35 copayment for each radiological diagnostic service. You have been asked to pay a $35 copayment for a CT scan. A CT scan 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 fora CT scan provided on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora nursing facility visit provided on September 27, 2018.You asked the Plan to pay forphysician visit. You say that initially the service was provided as self-pay, but you were advised to submit this claim to the Plan for coverage.The Plan denied your request. The Plan says the denial of payment for this service is correct because this claim was not submitted within the timely filing limit.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 physician visit was not filed until October 16, 2019. 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 foranursing facility visit provided on September 27, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee osteoarthritis. The documentation shows he has had limited physical therapy and no previous intra-articular steroid injections. The Medicare compendia do not support the use of intraarticular hyaluronic acid injections as first line injections. The Euflexxa is not reasonable or medically necessary at this time. 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 Euflexxa.
The Plan references Local Coverage Article (LCA) A56157 in their determination; however, this LCA is not binding for the Part B Medicare jurisdiction for the state of Utah and was not used in the MAXIMUS determination.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 5, 2019.
You asked the Plan to pay for the laboratory 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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture treatment (97811, 97810) provided from August 1, 2019 to December 18, 2019. You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that acupuncture treatment is not a covered benefit under your contractual policy. The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have
to pay for the acupuncture treatment (97811, 97810) provided from August 1, 2019 to December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea tertiary-level referral for an esophageal motility study.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthere are in-network non-tertiary level providers available who can perform the needed 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 referral. Our reviewer says that the requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer found the available records do not support the medical necessity for performance in a tertiary care facility of diagnostic testing that can be performed and has been prior authorized for performance by a local in-network specialist.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 referral have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea tertiary-level referral for an esophageal motility study.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).You asked the Planto pre-approvethe CGM. You say that you are visually impaired and cannot check your blood sugar without this device. You believe this should be covered because you do not want to have to prick your fingers to test your glucose.The Plandenied your request. The Plan says you do not meet the criteria for the CGM and it does not appear as if any provider has ordered this for you.The Plan must follow Medicare rules. Medicare rules say that CGMs are covered for enrollees who need to test their blood sugar four or more times per day and use this information for frequent adjustment of their insulin dosage. Based on the records provided, you do not require insulin to manage your condition. It is noted to be well-controlled on metformin. You do not meet the Medicare criteria for coverage of a CGM.Therefore, we decided that the Plandoes not haveto pre-approvea continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aids purchased August 10, 2018.You asked the Plan to pay forthe hearing aids. You say that you have always been told that there were no benefits with the plan and Medicare and you had just heard that the plan will process a claim for hearing aids paid out of pocket.The Plan denied your request. The Plan says the reimbursement request was filed after the time limit.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 hearing aids was not filed until October 31, 2019. 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 payforthe hearing aids purchased August 10, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forbilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on December 3, 2019.You asked the Plan to pay forthe orthoses and sleeves. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the medical records do notsupport this service.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses and sleeves have not been met. The documentation submitted did not indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay forbilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on December 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on August 8, 2018.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted does not include definitive laboratory results for 22 or more drug classes to support the coding criteria for HCPCS G0483.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

In this case, the CPT Code Manual definition of HCPCS code G0483 is "Drug test(s), deThe Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

In this case, the CPT Code Manual definition of HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed."

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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the review has determined that the records did not support the coding of HPCS G0483.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on August 8, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on May 1, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plansays the services are not covered.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on May 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Manual Wheelchair (K0001).
You asked the Plan to pre-approve the wheelchair. You say that a wheelchair is medically necessary. The Plan denied your request. The Plan says rules for coverage were not met.
The Plan follows Medicare rules. Medicare rules say that manual wheelchairs are covered when medically necessary and when an enrollee's condition cannot be improved by a walker or cane.
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 wheelchair. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the documentation does not reveal that the patient has a current mobility limitation that significantly impairs her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. The documentation does not reveal a detailed neuromuscular and gait evaluation indicating a need for this device or that if the patient has a mobility limitation that it cannot be improved with a walker or a cane. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Manual Wheelchair (K0001).