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

We decided that the Plan does not have to waive or reduce the $35 copayments charged for specialist services
provided from February 3, 2020, to December 7, 2020.
You asked the Plan to waive or reduce these copayments. You say that you should only have to pay for
supplies and not an office visit. The Plan denied your request. The Plan says these copayments were applied
based on the claim submitted by your provider and the Plan contract agreement. Maximus partially overturned
the Plans denial. The Plan requested a reopen and stated that the provider is within their right to charge this
copayment.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan
clearly says that you must pay a $35 copayment for specialist physician services.
When you send in your results or specimen or information to be reviewed, it requires a professional service to
process this information for you. Your provider has submitted a claim for these services. Therefore, a
copayment for each service applies. 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 or reduce the $35 copayments charged for specialist
services provided from February 3, 2020, to December 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 22, 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 codes 14301, 15733, 37600, and 14302 are 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 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The definition of code 14302 is adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure). The definition o code 15733 is muscle, myocutaneous, or fasciocutaneous flap; head and neck with named
vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae). The definition of code 37600 is ligation; external carotid artery. We find that CPT codes 14301, 15733, 37600, and 14302 are not supported in the medical record. Specifically, there is no documentation of adjacent tissue transfer or rearrangement for defects 30.1 to 60 sq cm to support code 14301. Given that primary procedure code 14301 is not supported, add-on code 14302 is also not supported. There is no documentation of a muscle, myocutaneous, or fasciocutaneous flap from the head to neck to support code 15733. There is no documentation of ligation of the carotid artery to support code 37600. 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 January 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) and core buildup (D2950) for tooth #6.
You asked the Plan to pre-approve a crown and core buildup. You say that this crown is medically necessary. The Plan denied your request. The Plan says they have already paid the $1,000 maximum allowance for routine dental services in 2021. Additional services will not be covered by the Plan.
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's dental benefit has a maximum benefit allowance of $1,000 per year for all supplemental dental services. Though the Plan offers a dental benefit in excess of Medicare coverage, the benefit does not offer coverage for items and services beyond the $1,000 annual maximum. Documentation shows that the Plan has already paid $1,000 for dental services for this enrollee in 2021. Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) and core buildup (D2950) for tooth #6.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunization administration services rendered on October 26, 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 were billed incorrectly.
The Plan must follow Medicare rules. The rules say that in situations in which the vaccine and the administration are furnished by two different entities, the entities should submit separate claims. We looked at the file and Medicare rules. The file shows that vaccine administration was billed separately with code 90471. The services should be billed with code G0008. Therefore, we decided that the Plan does not have to pay for the immunization administration services rendered on October 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve therapeutic CGM. You say that you disagree with this denial. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for a therapeutic CGM.
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, and 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 therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81404, 81405, 81406) provided January 18, 2021.
You asked the Plan to pay for the genetic testing. You say that the testing was medically necessary. The Plan denied your request. The Plan says the service cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that Medicare requires use of CPT 81479 (unlisted molecular pathology procedure) for reporting the Guardant360 panel assay. We looked at the file and Medicare rules. The service was not billed using CPT 81479. The testing was billed using unbundled CPT codes. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81404, 81405, 81406) provided January 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home oxygen concentrator and portable oxygen concentrator.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial oxygen saturation at or above 90%, home oxygen is not covered. We looked at the file and Medicare rules. The file shows that you have an oxygen saturation level of 95%. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a home oxygen concentrator and portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a health club membership (S9970).
You asked the Plan to pre-approve a health club membership. You say that the gym or fitness benefit should be covered and approved considering your delicate health. You need the gym/fitness benefit to be healthy and preventative. The Plan denied your request. The Plan says health club membership is not listed as covered under the Plan benefits.
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The services at issue in this appeal are gym benefits. Therefore, we decided that the Plan does not have to pre-approve a health club membership (S9970).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110) provided June 3, 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 CPT code 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 services were provided in the home setting. There is a more appropriate CPT code that describes these services (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 June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided to the enrollee on
March 16, 2021, by an out-of-network provider.
You asked the Plan to pay for the services. You say that the enrollee met indications for services performed.
The Plan denied your request. The Plan says no 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 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 outpatient hospital services provided to the
enrollee on March 16, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to urology for a third opinion.
You asked the Plan to pre-approve these services. You say that you would like a third opinion consultation. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that in the event that the recommendation of the first and second physician differs regarding the need for surgery (or other major procedure), a third opinion is also covered. We looked at the file and Medicare rules. You are requesting a third opinion with a urologist. The file shows that you have received a first and second opinion from network urologists and their opinions on your treatment did not differ. A third opinion is therefore not covered. Therefore, we decided that the Plan does not have to pre-approve a referral to urology for a third opinion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for dental orthodontist care.
You asked the Plan to pre-approve the dental service. You say that your dental plate has no support. You say that it is causing pressure to your gums. You also say that this is causing you pain. The Plan denied your request. The Plan says Medicare only covers dental services needed for radiation treatment for certain jaw-related diseases. The Plan also says that routine dental services are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Additionally, though the Plan offers a dental benefit in excess of Medicare coverage,
your general dentist must refer you to a participating dental specialist. Therefore, we decided that the Plan does
not have to pre-approve a referral for dental orthodontist care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) therapy rendered on December 5, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that TENS therapy for CLBP is covered when part of an approved clinical study. We looked at the file and Medicare rules. The file shows that the TENS therapy was not performed as part of an approved clinical study. 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 transcutaneous electrical nerve stimulation (TENS) therapy rendered on December 5, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from April 30, 2021, through
May 4, 2021.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that
the inpatient admission was not medically necessary. Observation status would have been sufficient. A five-day
hospital stay was not indicated.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found that the record showed that at the time of inpatient admission the admitting physician
reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or
observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from April 30, 2021, through May 4, 2021.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that you are in pain and barely able to walk. The Plan denied your request. The Plan says the services are available from network providers.
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 not a network provider with the Plan. The Plan has network providers 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. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gel-One injection for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this request does not meet the Part B step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not
trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan,
requires these be trialed first. The documentation does not outline contraindications or reasons these
medications were not considered. Without the support of the documentation, Gel-One is not approved, as step
criteria have not been met.
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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve a Gel-One injection for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for debridement provided from January 5, 2021, to January 20, 2021.
You asked the Plan to waive the copayments for debridement. You say that the Plan always covered the procedure in the past. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $260 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.
The enrollee received debridement on January 5, 2021, at an outpatient hospital facility. Debridement is considered an outpatient surgical procedure. Therefore, the enrollee is responsible to pay the allowed amount of $181.42, which is less than the $260 copayment. The enrollee received debridement on January 20, 2021, at an outpatient hospital facility. Debridement is considered an outpatient surgical procedure. Therefore, the enrollee is responsible to pay the allowed amount of $181.42, which is less than the $260 copayment. The total amount you owe is: $362.84. The enrollee has been asked to pay the total copayment amount of $362.84 for debridement. Debridement falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for debridement provided from January 5, 2021, to January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for interrogation device evaluation(s) (remote), up to 90 days;
single, dual, or multiple lead pacemaker system, leadless pacemaker system, or implantable defibrillator
system, remote data acquisition(s), receipt of transmissions and technician review, technical support and
distribution of results (CPT code 93296) provided to the enrollee on October 12, 2020, by an out-of-network
provider.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says this provider is out-of-network, the services were not referred by a network provider, and the
services were not urgent or emergent, nor were they approved in advance.
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 interrogation device evaluation(s) (remote), up to
90 days; single, dual, or multiple lead pacemaker system, leadless pacemaker system, or implantable
defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical
support and distribution of results (CPT code 93296) provided to the enrollee on October 12, 2020, by an outof-
network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your sacrotuberous ligament slips into the hamstring which goes from the heel to the waist contributing to the off stride of my right foot. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.