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

We decided that the Plan does not have to pay for anesthesia services provided on May 30, 2020.
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the diagnosis codes do not meet the specificity requirement for the 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. We asked our coder 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 anesthesia services. Our reviewer says that CPT code 0210 does not meet criteria for billing or reimbursement consideration. Our reviewer found the diagnosis codes do not meet the appropriate level of specificity required for the service that was rendered. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services provided on May 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 6, 2020.You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not supported by the documentation.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 the laboratory services are not supported in the medical record. Specifically, the documentation does not contain laboratory results for these services. 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 January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider from January 13, 2020, to February 10, 2020.You asked the Plan to pay forthe services. You say that the tests were medically necessary.The Plan denied your request. The Plan says the services are available in-network.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 forthe medical services provided to you by an out-of-network provider from January 13, 2020, to February 10, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in bathtub (A9270).
You asked the Plan to pre-approve the walk-in bathtub. You say that the bathtub is medically necessary. The
Plan denied your request. The Plan says bathtubs are not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a walk-in bathtub (A9270).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a MRI of the abdomen provided on November 27, 2019.You asked the Plan to pay for the MRI. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 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 a MRI of the abdomen provided on November 27, 2019.
Appeal type: Lab
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 January 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean extra heavy duty wheelchair and attachments for the enrollee.You asked the Plan to pre-approvean extra heavy duty wheelchair and attachments. You say that the enrollee requires a properly working wheelchair.The Plan denied your request. The Plan says that the enrollee does not meet criteria for this type of wheelchair.The Plan must follow Medicare rules. Medicare rules say that an extra heavy duty wheelchair is covered if the beneficiary weighs more than 300 pounds.We looked at the file and Medicare rules. The file indicates the enrollee does not weigh more than 300 pounds. Based on this information, we decided that Medicare rules for coverage of an extra heavy duty wheelchair and attachments have not been met.Therefore, we decided that the Plan does not have to pre-approvean extra heavy duty wheelchair and attachments for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient (92012) provided on December 4, 2019.You asked the Plan to waive the copayment forthe medical eye examination. You say that you had a routine annual eye exam and believe you should not have a copayment.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that the provider billed for a medical examination, not routine. You are asked to pay a $35 copayment for the medical eye exam. 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 forophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient (92012) provided on December 4, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forscanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve (92133) provided to the enrollee on January 10, 2020.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT code 92133 is one (1).You billed two (2)units of this code, exceeding the MUE. 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 forscanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve (92133) provided to the enrollee on January 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea home automatic blood pressure monitor (A4670).You asked the Plan to pre-approvethe home automatic blood pressure monitor. You say that you feel that this should be covered because you have purchase one because your primary care physician is requiring a virtual visit for your annual wellness visit due to COVID-19 pandemic.The Plan denied your request. The Plan says this is not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.Therefore, we decided that the Plan does not have to pre-approvea home automatic blood pressure monitor (A4670).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe x-ray services coded 72100 provided on January 13, 2020.You asked the Plan to pay forthe x-ray services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not separately payable.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 72100 for the x-ray services has a bundled relationship with code 72081 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 forthe x-ray services coded 72100 provided on January 13, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement forthe heavy duty walker provided on January 10, 2020.You asked the Plan to provide additional reimbursement forthe walker. You say that reimbursement provided was not enough to cover cost of device.The Plan denied your request. The Plan says that you cannot be provided reimbursement without proof of purchase.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 30% coinsurance for out-of-network services. You have asked the Plan to provide additional reimbursement for the walker. The walker falls within the out-of-network services benefit category. The Plan paid 70% of the allowable amount for the walker.Therefore, we decided that the Plan does not have to provide additional reimbursement forthe heavy duty walker provided on January 10, 2020.Please note: The Plan has indicated that they have requested you refund the monies that were paid to you for this item. MAXIMUS does not have jurisdiction to review this decision. We can only review appeals which have been filed in relation to an organization determination. The Plan is required to issue a new organization determination with appeal rights regarding the request for this refund. If you choose to appeal that determination and the Plan denies your appeal, the case will be forwarded to MAXIMUS under a new case number. You may wish to contact the Plan directly to inquire about the issuance of an official determination for the refund request
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wound care services provided on December 16, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the provider performed a medical procedure that was medically necessary.The Plan denied your request. The Plan says prior authorization was not obtained for 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 ofarea urgent care and pre-approved care.The documentation shows the enrollee was seen for a wound care follow-up. 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 forthe wound care services providedon December 16, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on October 16,
2019.
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says Medicare does not make separate
payment for this service.
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 95999 is not supported in the record. Specifically, train of four monitoring is ineligible
for separate reimbursement because it is considered integral to the primary procedure. Based on this
information, we decided that Medicare rules for coverage of the train of four monitoring have not been met.
Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on
October 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Iluvien (J7313).You asked the Plan to pre-approve the Iluvien. You say that you would like reconsideration as this drug is medically necessary.The Plan denied your request. The Plan says the use of this drug requires the member didn't have a clinically significant rise in intraocular pressure during previous treatment with a course of corticosteroids.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 the Iluvien. Our reviewer says that the member did have an intraocular pressure rise to 37 after treatment with Triesence (another corticosteroid). Therefore, the member would be deemed a steroid responder and Iluvien would not be considered a medically reasonable or necessary choice for this member. Our physician reviewer found the documentation supports that the member is a steroid responder and had a clinically significant rise in IOP after treatment with Triesence. Iluvien, another corticosteroid, would not be a safe alternative for the member and it would likely lead to another IOP spike and subsequent complications.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 Iluvien have not been met.Therefore, we decided that the Plan does not have to pre-approve Iluvien (J7313).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on October 25, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment ofthe enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items orderedand for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have topay fora lumbar-sacral orthosis (L0650) provided to the enrollee on October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.You asked the Plan to pre-approve the requested physician's services. The Plan denied your request. The Plan says the Plan requires you to receive care from providers who are part of your primary care physician's (PCP) specialty network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The contract with the Plan also says that the plan requires the enrollee to receive care from providers who are part of the enrollee's primary care physician's (PCP) specialty network.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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 19, 2019.
You asked the Plan to pay for the testing services. You say that the codes are supported by the physician's custom profile. The Plan denied your request. The Plan says the billed services cannot be verified.
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 the presumptive and definitive drug testing are not supported in the medical record. There is insufficient documentation that shows the testing was ordered by a physician who is treating the enrollee for a specific medical problem, and who uses the results in the management of the enrollee's specific medical problem. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea portable oxygen concentrator (E1390).You asked the Plan to pre-approvethe oxygen concentrator. You say that the requested system is medically necessary for travel.The Plan denied your request. The Plan says a portable oxygen system was already provided on January 15, 2018.The Plan must follow Medicare rules. The rules say Medicare covers DME onlywhen it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have a portable oxygen system. A portable oxygen system serves the same purpose as the oxygen concentrator.Therefore, we decided that the Plan does not have to pre-approvea portable oxygen concentrator (E1390)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 3, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 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 laboratory services provided on December 3,
2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxygen concentrator and portable oxygen rental.You asked the Plan to pre-approve oxygen concentrator and portable oxygen rental. You say that the enrollee needs oxygen.The Plan denied your request. The Plan says criteria is not met for home oxygen services.The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient must have tried other alternative treatments without complete success. The patient must meet one of the following blood gas levels:1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.We looked at the file and Medicare rules. The only documentation of oxygen saturation is from office notes which show 98% on room air. Based on this information, we decided that Medicare rules for coverage of oxygen concentrator and portable oxygen rental have not been met.Therefore, we decided that the Plan does not have to pre-approve oxygen concentrator and portable oxygen rental.