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

We decided that the Plan does not have to pre-approve Synvisc (J7325).

You asked the Plan to pre-approve Synvisc (J7325). You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to Orthovisc and Monovisc.

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 Synvisc (J7325). Our reviewer says that the drug is not reasonable or medically necessary. Our physician reviewer found the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc (J7325) have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Onetouch Ultra Blue test strips refills.
You asked the Plan to pre-approve Onetouch Ultra Blue test strips refills. You say that the item is medically necessary. The Plan denied your request. The Plan says you must use a Plan preferred brand of test strips.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Onetouch Ultra Blue test strips refills have not been met. Specifically, in order for glucose test strips to be approved you must use a Plan approved brand. Therefore, we decided that the Plan does not have to pre-approve Onetouch Ultra Blue test strips refills.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services provided on November 6, 2020.

You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 71045 is radiologic examination, chest; single view. We find that CPT code 71045 is not supported in the medical record. Specifically, this service was billed with diagnosis code Z87.891 (Personal history of nicotine dependence). This diagnosis code does not support the procedure. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services provided on November 6, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia injections (J0897).
You asked the Plan to pre-approve Prolia. You say that your doctor recommended that you get a Prolia injection. The Plan denied your request. The Plan says that rules for pre-approval have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that you need the requested medical service or item. Our physician reviewer found that, based on the medical records provided and the Medicare-approved major drug compendia, there is documentation that Prolia is medically reasonable and necessary for you. Prolia has been shown to improve bone mineral density (BMD) from baseline compared with placebo in a randomized study in postmenopausal women with low BMD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pre-approve Prolia injections (J0897).
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the esophagus x-ray (74220) provided on July 17, 2018.

You asked the Plan to pay for the x-ray. You say that you would like reconsideration because filing deadlines have been waived due to COVID-19. The Plan denied your request. The Plan says the receipt date applied to the claim exceeds 12 months or 1 calendar year from the date the services were furnished.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the x-ray was not filed until October 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the esophagus x-ray (74220) provided on July 17, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services identified with codes 36415, 80048,
85025, 86360, 86361, and J7030 provided on September 16, 2020.
You asked the Plan to pay for these medical services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 36415, 80048, 85025, 86360, 86361, and J7030 are not supported in the medical
record. Specifically, payment cannot be separately made to any provider or supplier other than the facility for
services furnished to the enrollee for surgery. The facility must furnish all necessary covered services to the
enrollee either directly or under arrangements made between the facility and outside vendors. The enrollee
received these services in preparation for a procedure at the facility. Payment for this service would be included
in the facility Prospective Payment System (PPS) payment. Payment for this service is the responsibility of the
facility. Based on this information, we decided that Medicare rules for coverage of these medical services have
not been met. Therefore, we decided that the Plan does not have to pay for the medical services identified with
codes 36415, 80048, 85025, 86360, 86361, and J7030 provided on September 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power operated vehicle (POV) (K0806).
You asked the Plan to pre-approve POV. You say that the item is medically necessary. The Plan denied your request. The Plan says the primary use for the group 2 POV is for outside the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve power operated vehicle (POV) (K0806).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging and does not have to waive the coinsurance for Medicare Part B drugs provided on July 1, 2020.

You asked the Plan to waive the copayment for myocardial perfusion imaging and to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the charges. 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 $75 copayment for nuclear medicine tests and 20% coinsurance for Part B medications and contrast agents injected during a service. 

You received myocardial perfusion imaging and Medicare Part B drugs on July 1, 2020. Therefore, you are responsible to pay your share of the cost-sharing charges.

The total amount you owe is: $169.48.

You have been asked to pay the total amount of $169.48 for myocardial perfusion imaging and Medicare Part B drugs. Myocardial perfusion imaging and Medicare Part B drugs 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 copayment for myocardial perfusion imaging and does not have to waive the coinsurance for Medicare Part B drugs provided on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on August 27, 2020.

You asked the Plan to pay for the dental service. You say that you were unaware that the procedures that you received was for periodontal maintenance instead of prophylaxis. You say that the last time you saw this provider you received prophylaxis. The Plan denied your request. The Plan says periodontal maintenance is not listed as a covered service.

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, the requested items or services are not among those covered under this benefit. The record shows that the Plan contacted the provider's office and confirmed the corrected service, periodontal maintenance, was billed. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on August 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous sacral augmentation (sacroplasty) for the enrollee.

You asked the Plan to pre-approve percutaneous sacral augmentation (sacroplasty) for the enrollee. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the Medicare LCD coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria in the LCD.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for sacroplasty.
The Maximus Physician Reviewer determined the treatment to be reasonable and necessary. The Plan requested a reopen and stated that the criteria outlined in the relevant LCD L35130 were not met in this case.
Our Medical Director says that the medical records show the enrollee the enrollee is an 88-year-old woman with bilateral sacral fractures. Our Medical Director has concluded the Plan is correct in this case. Per LCD L35130, Percutaneous Vertebral Augmentation for Vertebral Compression Fracture services are not indicated for the sacrum or coccyx. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous sacral augmentation (sacroplasty) have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous sacral augmentation (sacroplasty) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Vitamin D testing (82306), Cyanocobalamin testing (82607), and folic acid testing (82746) provided on July 9, 2020.

You asked the Plan to pay for Vitamin D testing, Cyanocobalamin testing, and folic acid testing. You say that these services should be covered. The Plan denied your request. The Plan says these services were performed for screening purposes.

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 test at issue in this appeal, Vitamin D testing, Cyanocobalamin testing, and folic acid testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.

Therefore, we decided that the Plan does not have to pay for Vitamin D testing (82306), Cyanocobalamin testing (82607), and folic acid testing (82746) provided on July 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the treatment of lumbar spinal stenosis. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the spacer remains 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says you have not completed a four week trial of basic PCD.
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 (PCD) (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for neck free shoulder system (L3960) provided on October 7, 2020.
You asked the Plan to pay for neck free shoulder system. You say that the service is medically necessary. The Plan denied your request. The Plan says there is insufficient documentation proving medical necessity.
The Plan must follow Medicare rules. The rules 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 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 neck free shoulder system. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of a credible physical examination of the shoulder. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neck free shoulder system have not been met. Specifically, insufficient documentation has been provided to indicate medical necessity for this item. Therefore, we decided that the Plan does not have to pay for neck free shoulder system (L3960) provided on October 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthoses and suspension sleeves (L2397, L1833).
You asked the Plan to pay for knee orthoses and suspension sleeves. You say that these services were medically necessary The Plan denied your request. The Plan says medical records do not provide evidence that the provider examined the member before services were rendered.
The Plan follows Medicare rules. Medicare rules say that knee instability must be documented by examination of the beneficiary and objective description of joint laxity. 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 orthoses and suspension sleeves. Our reviewer says that the items were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, 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 orthoses and suspension sleeves have not been met. Therefore, we decided that the Plan does not have to pay for knee orthoses and suspension sleeves (L2397, L1833).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar brace (L0650) provided on October 2, 2020.
You asked the Plan to pay for lumbar brace. You say that the item is medically necessary. The Plan denied your request. The Plan says the plan was unable to discover any evidence of an established relationship between the member and the ordering physician. There were no claims submitted for an evaluation and management service. Review of claims history for this member, and a review of the submitted documentation did not contain evidence of a relationship with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. The rules 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 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 lumbar brace. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not appear to be based upon an established physician-patient relationship or an in-person physical examination. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar brace have not been met. Specifically, insufficient documentation was submitted indicating the medical necessity of this item. Therefore, we decided that the Plan does not have to pay for lumbar brace (L0650) provided on October 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on March 12, 2020.
You asked the Plan to waive the copayment for an X-ray. You say that you were not charged in the past and disagree with the charges. 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 X-rays provided in a primary care physician's office and a $90 copayment when provided by any other provider. You have been asked to pay a $90 copayment for an X-ray. An X-ray falls 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 copayment for an X-ray provided on March 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammogram provided on November 4, 2020.

You asked the Plan to pay for the mammogram. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a mammogram provided on November 4, 2020.