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

We decided that the Plan does not have to pay for laboratory testing provided on June 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and 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 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 laboratory testing provided on June 9, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth visit provided on January 18, 2021.
You asked the Plan to waive the copayment for a telehealth visit. You say that you were diagnosed without examined and are unhappy with the care you received. 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 $5 copayment for primary care provider visits. The medical records show that you had a telehealth visit on January 18, 2021. Therefore, you are responsible to pay the $5 copayment.
You have been asked to pay a $5 copayment for a telehealth visit. A telehealth visit falls within the physician/practitioner services, including doctor's office visits 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 a telehealth visit provided on January 18, 2021.
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth office visit (99214) provided on January 11, 2021.
You asked the Plan to pay for a telehealth office visit. You say that Medicaid providers have been instructed to use the home place of service code for telehealth services. The Plan denied your request. The Plan says this was not billed with the correct POS.
The Plan must follow Medicare rules. Medicare rules say that providers should submit telehealth services claims using Place of Service (POS) 02-Telehealth to indicate they furnished the billed service as a professional telehealth service from a distant site.
We looked at the file and Medicare rules. The telehealth service at issue was not billed with POS 02. Based on this information, we decided that Medicare rules for coverage of a telehealth office visit have not been met. Therefore, we decided that the Plan does not have to pay for a telehealth office visit (99214) provided on January 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT angiography of the neck.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says there are no results from prior imaging included in the records.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically 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 scan. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found the most recent
physical exam from 5/11/21 revealed a normal neck. There was no palpable abnormality described, and no
bruit was present, or at least described. A review of the ultrasound report of 9/20/20 showed a normal
appearing carotid bulb and no enlarged lymph nodes. If there is still concern about the anatomy of the neck a repeat ultrasound would be of use. Currently there are no physical findings documented to provide an indication for CTA of the neck and the prior ultrasound was normal. 

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT angiography of the neck.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on March 26, 2021.

You asked the Plan to waive the copayment for an EGD. You say that this should be considered a preventative procedure and you should not be charged 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 there are no cost-sharing charges for colorectal cancer screenings. Your contract with the Plan also clearly says that you must pay a $285 copayment for outpatient surgery, including services provided at hospital outpatient facilities. 

You received an EGD on March 26, 2021, at an outpatient hospital facility. An EGD is considered a diagnostic outpatient surgical procedure, not preventative, and you are responsible to pay the $285 copayment. 

You have been asked to pay a $285 copayment for an EGD. An EGD falls 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 an EGD provided on March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the services provided in an urgent care
center (S9088), the office visits (99213, 99214), x-ray exam of the ankle (73610), and a light compression
bandage (A6449) provided on March 15, 2021 and April 10, 2021.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to
the services provided.
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 $65
copayment for each urgent care visit.
You have been asked to pay $130 ($65 copayment x 2) for the urgent care visits provided. This means that you
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayments for the services provided in an urgent care center (S9088), the office
visits (99213, 99214), x-ray exam of the ankle (73610), and a light compression bandage (A6449) provided on
March 15, 2021 and April 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on October 31, 2020.
You asked the Plan to pay for Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf (L1833LT) and Addition to lower extremity orthosis, suspension sleeve (L2397LT). You say that the orthoses are medically necessary. The Plan denied your request. The Plan says the provider prescribed the orthoses without a face-to-face evaluation, physical examination or imaging demonstrating medical necessity.
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 Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf (L1833LT) and Addition to lower extremity orthosis, suspension sleeve (L2397LT). Our reviewer says that the orthoses are not medically reasonable and necessary. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf (L1833LT) and Addition to lower extremity orthosis, suspension sleeve (L2397LT) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on October 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endoscopic sinusotomy.
You asked the Plan to pre-approve endoscopic sinusotomy. 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 endoscopic sinusotomy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the case file contains insufficient documentation of failure of recent medical treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of endoscopic sinusotomy have not been met. Therefore, we decided that the Plan does not have to pre-approve endoscopic sinusotomy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological services provided on March 31, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the ophthalmological services. You say that the benefits booklet does not say that medically required vision evaluations need to be in network. The Plan denied your request. The Plan says no prior authorization was 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 ophthalmological services provided on March 31, 2021 by an out of network (OON) provider.
Your complaint about the Plan's poor customer service is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 31, 2020.

You asked the Plan to pay for the services provided. You say that the medical necessity of the testing has been extensively studied. The Plan denied your request. The Plan says the claim was processed correctly.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer.

However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services provided until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the lab services provided on December 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425, A0427) received December 10, 2020.

You asked the Plan to waive the copayment for the ambulance transportation. You say that the copayment should be waived because you were admitted to the hospital for five days. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 $225 copayment for Ambulance Services.

You have been asked to pay a $225 copayment for the ambulance transportation. the ambulance transportation falls within the Ambulance 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 the ambulance transportation (A0425, A0427) received December 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on March 17, 2021.
You asked the Plan to pay for the physical therapy. You say that the patient was seen for physical therapy for left shoulder pain. You say that the authorization should be approved, and the claim should be reprocessed. The Plan denied your request. The Plan says prior authorization was required but 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 physical therapy provided by an out-of-network provider on March 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Octagam injection.

You asked the Plan to pre-approve the Octagam injection. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says this request does not meet Medicare or FDA coverage criteria.

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 Octagam injection. Our reviewer says that the Medicare approved drug compendia contain supportive citations for the use of the requested drug for exacerbations of myasthenia gravis.

The local coverage determination states that this treatment is supported for Myasthenia Gravis (MG) in patients who have profound, rapidly progressive and/or potentially life-threatening muscular weakness and are refractory to, or intolerant of cholinesterase inhibitors, corticosteroids and azathioprine. Our physician reviewer found the record indicates that the enrollee has myasthenia gravis without exacerbation. The elements of the coverage criteria are not satisfied. 

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 Octagam injection have not been met. Therefore, we decided that the Plan does not have to pre-approve the Octagam injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatology services provided on July 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the services are available within the 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 OON services. Therefore, we decided that the Plan does not have to pay for the dermatology services provided on July 6, 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 urine panel testing provided on September 28, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says experimental or investigational services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

We looked at the file and the rules. The records provided do not indicate the results of the testing would be used in the management of a specific medical problem. The testing services were requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the urine panel testing provided on September 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the pelvic x-ray rendered on November 24, 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 are 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 72170 (pelvic x-ray) and 73502 (hip x-ray). Code 72170 is a column II code with a modifier indicator of 1 when billed with column I code 73502. Code 72170 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 pelvic x-ray rendered on November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.

You asked the Plan to pre-approve the compression stockings. You say that you have heard that these are
covered items. The Plan denied your request. The Plan says gradient compression stockings coded as A6530
are statutorily non-covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are
noncovered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued office visits with an out-of-network (OON) provider.

You asked the Plan to pre-approve continued office visits. You say that it is medically necessary for the enrollee to continue to receive care from an OON provider. The Plan denied your request. The Plan says they have in-network providers available to treat the enrollee's condition.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs.

The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. 

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 continuation of care. Our reviewer says that the requested OON office visits are not medically necessary. Our physician reviewer found the enrollee is an 88-year-old diagnosed with chronic kidney disease has been under the care of a tertiary nephrologist since October 2020.There is no specific clinical rationale for continued tertiary out of network follow-up visits. The requested services are available within the network with a Nephrologist who specializes in chronic kidney disease, acute and chronic dialysis, diabetic kidney disease, electrolyte problems, end stage renal disease (ESRD), glomerulonephritis, nephropathy and kidney failure prevention counseling. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued office visits with an out-of-network (OON) provider.