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

We decided that the Plan does not have to pre-approve a referral to a provider outside of your referral circle.
You asked the Plan to pre-approve these services. You say that you need maintenance treatment after surgery. The Plan denied your request. The Plan says the services are available from providers within your referral circle.
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 requested provider in this case is a network provider with the Plan but is not a provider within your primary care physician (PCP)'s referral circle. The Plan has providers within your PCP's referral circle available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. You may change your PCP to one who refers to this provider if you wish to receive services. Therefore, we decided that the Plan does not have to pre-approve a referral to a provider outside of your referral circle.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on March 9, 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 procedure code 21215 is 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 21215 is graft, bone; mandible (includes obtaining graft). 

We find that CPT code 21215 is not supported in the medical record. Specifically, there is no documentation of a mandible bone graft. 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 March 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient behavioral health hospitalization for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says outpatient level of care with supportive housing is appropriate.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on October 19, 2020 with Major Depressive Disorder, Borderline Personality Disorder and TBI. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did at passive suicidal no homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment, while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did have passive dangerousness to self but not others and was compliant with her treatment. The health plan's denial of continued inpatient psychiatric services is appropriate. 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 pre-approve continued inpatient behavioral health hospitalization for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET scan of the heart with CT for attenuation.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have increased coronary risk but symptoms that do not sound anginal (nonexertional, last seconds) and no ischemia on stress echocardiography at a diagnostic cardiac workload including no chest pain during exercise, no documented ischemic ECG changes and no ischemia by echo imaging. The stress test results were nor reported as equivocal. Overall the documentation does not support the medical necessity for cardiac PET imaging, since his symptoms do not sound anginal and the stress test results are not significantly equivocal or nondiagnostic. 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 pre-approve PET scan of the heart with CT for attenuation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is a minimally invasive procedure, and is a safer alternative to a laminectomy or spinal fusion. The Plan denied your request. The Plan says there is no enrollment in a Medicare-approved study looking at the benefits of this device.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 11, 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 a participating provider. The Plan says that the referring provider is out-of-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 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 September 11, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 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 procedure code 88341 is 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 88341 is immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure). We find that CPT code 88341 is not supported in the medical record. Specifically, this is an add-on code that was not billed with a required primary procedure code. 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 laboratory services rendered on August 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health service (H0018) rendered by the out of network (OON) provider on July 31, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the behavioral health service (H0018) rendered by the out of network (OON) provider on July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on June 30, 2020.
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that the provider told you that you were approved to get dentures. The Plan denied your request. The Plan says these services exceed the maximum allowed per period.
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, complete maxillary denture (D5110) and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and complete mandibular denture (D5120) on May 18, 2018, and your complete maxillary denture (D5110) and complete mandibular denture (D5120) has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on June 30, 2020.
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that the provider told you that you were approved to get dentures. The Plan denied your request. The Plan says these services exceed the maximum allowed per period.
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, complete maxillary denture (D5110) and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and complete mandibular denture (D5120) on May 18, 2018, and your complete maxillary denture (D5110) and complete mandibular denture (D5120) has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on June 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for manipulation of the knee joint (27570) provided on March 27, 2020.
You asked the Plan to pay for the manipulation of the knee joint. You say that you would like reconsideration because these services were billed correctly. The Plan denied your request. The Plan says the maximum frequency per day for this service is 1.
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 27570 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the manipulation of the knee joint have not been met. Therefore, we decided that the Plan does not have to pay for manipulation of the knee joint (27570) provided on March 27, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay for positron emission tomography (PET) with concurrently acquired computed tomography (CT) billed with CPT 78816 and a diagnosis code of C83.30.

You asked the Plan to pay for imaging services provided to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that the Medicare billing guidelines say claims for FDG PET scans must be submitted with the correct CPT codes, modifiers and diagnosis codes. Medicare Claims Processing Transmittal 3162, section 60.16 entitled Billing and Coverage Changes for PET Scans, identifies appropriate diagnosis codes for the FDG PET scans. The denied claim was submitted with a diagnosis code of C83.30, which is not identified as an appropriate diagnosis code per the CMS transmittal.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate diagnosis codes. Review of Medicare Claims Processing Transmittal 3162, section 60.16 confirms that diagnosis code C83.30 is not listed as a covered code. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for positron emission tomography (PET) with concurrently acquired computed tomography (CT) billed with CPT 78816 and a diagnosis code of C83.30.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is lack of documentation of improvement from previous treatments to the same levels.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the return of pain after her second RFA did not demonstrate efficacy and should not be repeated. Therefore, the request is not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic radiofrequency ablation for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and
(b).
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that enrollees must pay a 20% coinsurance for chemotherapy drugs. You can find this information
on page 77 of the Plan's 2020 EOC.
The Plan contract says that enrollees must pay a $50 copayment for physician specialist services. You can find
this information on page 87 of the Plan's 2020 EOC.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group two power wheelchair.

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found your mobility deficit is helped by a walker. The documentation does not support that this requested wheelchair is medically necessary and will significantly improve MRADL participation in the home. 

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 group two power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99214) provided October 12, 2020.

You asked the Plan to waive the copayment for the office visit. You say that you were not charged a copayment for this service in the past. The Plan denied your request. The Plan says the correct copayment was applied.

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 $40 copayment for Outpatient Mental Health Services. 

You have been asked to pay a $40 copayment for the office visit. The office visit falls within the Outpatient Mental Health Services 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 an office visit (99214) provided October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 20, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. 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 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided on April 20, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional hours of neuropsychological testing.

You asked the Plan to pre-approve the additional hours. You say that this is medically necessary. The Plan
denied your request. The Plan says additional hours above the initial eight hours is not reasonable or necessary
at this time.

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 additional hours. Our reviewer says
that the requested additional hours are not considered medically reasonable and necessary in this case. Our
physician reviewer found you have not shown any impairment in functioning as you are able to take care of
your wife. You have been showing difficulty with memory issues and have a history of substance use
problems. Based on review the records provided in the information provided, you do not meet the criteria for
additional neuropsychological testing beyond which is approved. The request is for an excessive amount of
testing.

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 additional hours have not been met. Therefore, we decided that the Plan
does not have to pre-approve additional hours of neuropsychological testing.