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

We decided that the Plan does not have to waive the co-payments for myocardial perfusion imaging and a stress test provided on January 28, 2021, and February 9, 2021.

You asked the Plan to waive the co-payments for myocardial perfusion imaging and a stress test. You say that you feel that the charges are too high. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 co-payment for each advanced imaging service and a $5 co-payment for diagnostic procedures and tests.

You received myocardial perfusion imaging on January 28, 2021. Therefore, you are responsible to pay the $200 co-payment.

You received a stress test on February 9, 2021. Therefore, you are responsible to pay the $5 co-payment. 

The total amount you owe is: $205.

You have been asked to pay the total co-payment amount of $205 for myocardial perfusion imaging and a stress test. Myocardial perfusion imaging and a stress test fall 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 co-payments for myocardial perfusion imaging and a stress test provided on January 28, 2021, and February 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your request is not medically necessary because you did not send any records for review.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Specifically, medical records were not provided for review in this case. The record shows that the Plan made multiple attempts to secure medical records, without success. Without medical records, we cannot determine if Medicare criteria are met in this case. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray you had on October 1, 2020.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the copayment.
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 $20 copayment per visit for x-rays. Review of the file shows that you were provided an x-ray on October 1, 2020. You have been asked to pay a $20 copayment for the x-ray. The x-ray falls within the outpatient diagnostic 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 x-ray you had on October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a continuous glucose monitor (CGM).
You asked the Plan to preapprove the CGM. You say that the CGM should be covered as you've used one in the past. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomics testing panel provided on October 29, 2020.
You asked the Plan to pay for the testing services. You say that the testing has been properly coded. The Plan denied your request. The Plan says one CPT code must be submitted for the panel.
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 looked at the file and the rules. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomics testing panel provided on October 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided on November 27, 2020.
You asked the Plan to pay for an x-ray. You say that this was billed globally to include both the professional and technical components. The Plan denied your request. The Plan says this was not billed with a required modifier.
The Plan must follow Medicare rules. Medicare rules say that Medicare may not pay for the technical component (TC) of radiology services furnished to Skilled Nursing Facility (SNF) inpatients during a Part A covered stay. We looked at the file and Medicare rules. The record shows that the enrollee was in an SNF stay at the time of service, but the x-ray at issue was not billed with a modifier to indicate that only the professional component, not the technical component, is being billed.
Based on this information, we decided that Medicare rules for coverage of an x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided on November 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110) provided August 11, 2020.
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 97110 is not supported in the medical record. Specifically, the records show the service was provided in the home setting. There is a more appropriate CPT code for this service in this setting (G0157). Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97110) provided August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additional reimbursement for eyewear purchased on February 19, 2020.
You asked the Plan to pay for additional reimbursement for this eyewear. You say that you believe the Plan did not pay its share. The Plan denied your request. The Plan says payment for this eyewear was made based on the Plan contract agreement and the cost of eyewear you purchased. Maximus overturned the Plans denial stating insufficient information had been provided regarding the claim. The Plan requested a reopen and provided additional clarification on the claim submitted. The Plan states the retail value of the eyewear purchased was $740. The Plan states the contract is clear that the annual eye wear allowance is applied to the retail value only. Taxes are not included and members are responsible for any amount over the $250 allowance.
The Plan states the $250 applied to the $740 retail value, leaving a balance of $490. The provider only charged $392 due to some other discounts. The provider was paid their contractual rate of $150. The eyewear allowance was applied in full to the retail cost and is unrelated to the providers payment for dispensing the eyewear.
We find the Plan is correct in this case. Medicare does not cover routine vision and eyewear services. The Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan up to $250 for eyewear which is applied to the total retail cost. Your vision benefit was fully applied. Any cost remaining after the $250 is applied is your financial responsibility. Therefore, we decided that the Plan does not have to pay additional reimbursement for eyewear purchased on February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on August 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for podiatry services. You say that you would like this claim reprocessed and paid. You say that these services were medically necessary. The Plan denied your request. The Plan says there are in-network providers available for these services. The plan says that prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 podiatry services provided on August 14, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultra lightweight manual wheelchair and components.
You asked the Plan to pre-approve an ultra lightweight manual wheelchair and components. You say that you need a break away manual wheelchair to travel and drive your new car. The Plan denied your request. The Plan says that payment is made for only one wheelchair at a time.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when 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 power wheelchair. A power wheelchair serves the same purpose as an ultra lightweight manual wheelchair and components. Therefore, we decided that the Plan does not have to pre-approve an ultra lightweight manual wheelchair and components.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections in the spine (62321) provided on February 8, 2021, by an out of network (OON) provider.

You asked the Plan to pay for injections in the spine. You say that services were rendered due to an emergency case. The Plan denied your request. The Plan says services were provided 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 injections in the spine (62321) provided on February 8, 2021, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar interspinous process stabilization device procedures.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device (22869, 22870). You say that you need this device for pain relief of your chronic lower back pain. The Plan denied your request. The Plan says there are not enough studies to show that use of the device is better than regular spine surgery.

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 insertion of interlaminar/interspinous process stabilization/distraction device (22869,22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device 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 insertion of interlaminar/interspinous process stabilization/distraction device (22869, 22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve the lumbar interspinous process stabilization device procedures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gel pressure mattress pad (E0185).
You asked the Plan to pre-approve a gel pressure mattress pad. You say that this is necessary to prevent ulcers.
The Plan denied your request. The Plan says no records have been received to show that the requirements for
coverage have been met.
The Plan must follow Medicare rules. Medicare rules say that a Group 1 mattress overlay or mattress is covered
is the enrollee is completely immobile, has limited mobility, or has a pressure ulcer. The rules also say for
Medicare to consider coverage and payment for any item or service, the information submitted by the supplier
or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that
Medicare coverage criteria have been met.
We looked at the file and Medicare rules. No medical records have been submitted to show whether you have a
condition that meets the requirements for coverage. Based on this information, we decided that Medicare rules
for coverage of a gel pressure mattress pad have not been met. Therefore, we decided that the Plan does not
have to pre-approve a gel pressure mattress pad (E0185).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and pneumatic appliance (E0667).
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you respectfully disagree with the denial and feel that the enrollee's clinical presentation necessitates treatment with the prescribed device. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no evidence of lymphedema extending to the chest, trunk and/or abdomen and there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and pneumatic appliance (E0667).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services rendered on January 15, 2021.
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 37253 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 37253 is intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure). We find that CPT code 37252 is not supported in the medical record. Specifically, the operative report does not include documentation of an intravascular ultrasound during diagnostic evaluation. 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 37225 (endovascular revascularization) and 75710 (unilateral extremity ultrasound). Code 75710 is a column II code with a modifier indicator of 1 when billed with column I code 37225. Code 75710 was not billed with an appropriate modifier to allow for separate payment. 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 imaging services rendered on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the gingival irrigation (D4921 x 4), periodontal scaling and root planing (D4341 x 2), the drugs and medicaments (D9630), and the antimicrobial agents (D4381 x 4) provided from December 28, 2020, to December 29, 2020.
You asked the Plan to pay for the dental services. You say that your policy for 2020 covers up to $4,000 for dental services. You say that the Plan has only paid $3,794.20. You also say that there is a remaining balance of $205.80. The Plan denied your request. The Plan says that there is a $4,000 yearly allowance for covered preventive and comprehensive dental services combined. The Plan also says that the annual allowance has been exhausted.
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. The Plan covers the dental services when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met. The record shows that you were disenrolled from this plan at the beginning of 2020 and the contract ended. The record shows that you were signed up for this plan after disenrolling from another one, effective September 1, 2020. Only the services provided since September 1, 2020 would apply towards the $4,000 maximum allowance.
Date of Service
Plan Paid
10/6/2020
$979
10/7/2020
$196
12/7/2020
$121
12/28/2020
$1,107.89
TOTAL:
$2,282.89
Therefore, we decided that the Plan has to pay for the gingival irrigation (D4921 x 4), periodontal scaling and root planing (D4341 x 2), the drugs and medicaments (D9630), and the antimicrobial agents (D4381 x 4) provided from December 28, 2020, to December 29, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80053, 80061, 82607, 83036, 85025) provided September 16, 2020.
You asked the Plan to pay for the lab services. You say that the lab tests were medically necessary. The Plan denied your request. The Plan says the tests were ordered for screening purposes and therefore 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. The tests at issue in this appeal were requested solely for screening purposes. The plan made multiple requests for additional clinical documentation to support the tests. None was obtained. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (80053, 80061, 82607, 83036, 85025) provided September 16, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve prosthesis items for the enrollee.

You asked the Plan to pre-approve the requested items. You say that the enrollee is unstable with his current socket, and it limits his abilities for daily living. The Plan denied your request. The Plan says that the documentation does not show that the requested items are no longer function and need to be replaced.

The plan follows Medicare rules. Medicare rules say that prosthetic devices are only covered for certain medical indications.
The file shows that a multi-axial rotation unit (CPT L5986), and a shank foot system with vertical loading pylon (CPT L5987) was requested for the enrollee. We looked at the doctor's review, the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested items have been met. Therefore, we decided that the Plan has to pre-approve prosthesis items for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The health plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.