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

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427, A0425) provided on September 7, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you feel the cost is too high for such a short trip. The Plan denied your request. The Plan says ambulance services require a $250 copayment for each one-way trip.
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 $250 copayment for ambulance services. You have been asked to pay a $250 copayment for the ambulance transportation. Ambulance transportation services are subject to a $250 copayment for each one-way trip. 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 (A0427, A0425) provided on September 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens (17311) repair, complex, scalp, arms, and/or legs (13121).

You asked the Plan to pay for Mohs Micrographic Surgery Procedures. You say that you needed to have Mohs surgery. You called the plan and asked for an in-network provider and was given this doctor. Now you are told he is out of network. The Plan denied your request. The Plan says the enrollee had not met their 2020 $950 out of network deductible. The current balance is $849.81.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $950 deductible. This is the amount you have to pay out of pocket before the plan will pay their share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services.

The item or service you asked the Plan to pay for falls within the benefit category the deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $950 deductible. This cost sharing is a contractual obligation that had not been met at the time Mohs Micrographic Surgery Procedures. Therefore, we decided that the Plan does not have to pay for Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens (17311) repair, complex, scalp, arms, and/or legs (13121).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on August 13, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 95999 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 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that Train of Four testing was performed and there is a more appropriate code for these services. 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 testing services rendered on August 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT).

You asked the Plan to pre-approve IGRT. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 IGRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the enrollee's tumor is located very close to sensitive organs and structures, or that the tumor is likely to move.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external ambulatory infusion pump (Insulin Pump).

You asked the Plan to pre-approve an insulin pump. You say that the item is necessary. The Plan denied your request. The Plan says you currently already have the requested item and that it is still fully functional. Therefore, coverage criteria have not been met.

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 an insulin pump. Therefore, we decided that the Plan does not have to pre-approve an external ambulatory infusion pump (Insulin Pump).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments charged for specialist physician visits.

You asked the Plan to waive these copayments. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says the cost share for both the injections and the physician services was charged 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 provided the correct Plan contract agreement.

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 $35 copayment for each specialist office visit and 20% coinsurance of Medicare Part B injections. You have been asked to pay the correct amount based on the services provided and 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 charged for specialist physician visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (93010) provided on June 1, 2020.
You asked the Plan to pay for these diagnostic services. You say that this claim should be paid. The Plan denied your request. The Plan says this claim was included in the facility payment and cannot be billed separately. Maximus overturned the Plans denial. The Plan requested a reopen and stated that this is not a medical coverage denial, this is an administrative denial. The Plan says that this claim was inappropriately billed. The Plan says the facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made between the facility and outside vendors. The enrollee received the services in preparation for surgery at the facility. Payment for this service would be included in the facility payment. The Plan has based its billing denial on the Code of Federal Regulations (CFR) 42 CFR 409.3 as well as the Code of Federal Regulations (CFR) 42 CFR 412.50. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and bill under the appropriate circumstances. In this case, payment for pre-admission diagnostic services is included in the facility payment and is not separately billable. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (93010 ) provided to the enrollee on June 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) genetic testing panel provided on August 9, 2020 billed with code 81455.
You asked the Plan to pay for the F1Heme panel. You say that this testing was validated by the Centers for Medicare and Medicaid Service and cannot be denied by a Medicare Advantage plan. You provide reference to an LCD L38047 as evidence of coverage. The Plan denied your request. The Plan says there are numerous Medicare coverage rules which indicate that this type of panel must be billed with code 81479 along with the DEX Z-code. As such, this was incorrectly coded and cannot be paid.
Maximus reviewed the regulations cited by both the lab and the Plan. We find that these regulations do not apply either to the State in which this testing was performed or for the specific type of testing at issue. As such, our review is based on the regulations noted in the Medicare Rules section.
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to support the medical necessity of Genomic Sequential Analyses panels for patients with CML for a limited number of individual biomarkers. Panels which test the covered biomarkers and are described by code 81450 may be covered by Medicare. We looked at the file and Medicare rules. Review of the information in the file shows that this panel includes analysis of over 50 genes. The billed code 81455 is defined as targeted genomic sequencing with analysis for 51 or more genes. Although some of these genes may be considered medically necessary based on the rules, the entire panel exceeds what is covered under these provisions.
Based on this information, we decided that Medicare rules for coverage of the F1Heme panel have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) genetic testing panel provided on August 9, 2020 billed with code 81455.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove the group 3 power wheelchair (PWC) with multiple power options including power seating and power tilt.
You asked the Plan to preapprove the PWC. You say that the enrollee requires the device. The Plan denied your request. The Plan says the enrollee may require a group three power wheelchair, but the group three power wheelchair with multiple power options is not necessary.
The Plan must follow Medicare rules. Per Medicare criteria, Group 3 power wheelchair with Multiple Power Options is reasonable and necessary when the member uses a ventilator mounted to the wheelchair or when the member meets coverage criteria for a power tilt and power recline seating system. Neither of these conditions applies to this member. Therefore, the request for K0861 Group 3 power wheelchair with Multiple Power Options is not reasonable and necessary. Therefore, we decided that the Plan does not have to preapprove the group 3 power wheelchair (PWC) with multiple power options including power seating and power tilt.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit.

You asked the Plan to waive the copayment for the telehealth visit. You say that you did not have a virtual visit you only requested a prescription refill. You say that you are requesting a reduction that falls into your income equivalencies. The Plan denied your request. The Plan says the copayment applied correctly.

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 $45 copayment for each specialist office visit for Medicare-covered services. Covered services include certain telehealth services, including for general medical issues, mental health issues and dermatological conditions. You have the option of receiving these services either through an in-person visit or via telehealth visit.

You have been asked to pay a $45 copayment for the telehealth visit. The telehealth visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show a 13-minute telehealth visit with a specialist was provided to discuss treatment options. 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 telehealth visit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for exercise equipment (A9300) purchased August 21, 2020.
You asked the Plan to pay for exercise equipment. You say that you were unaware you would be reimbursed if you had waited to purchase the equipment. The Plan denied your request. The Plan says rules for payment have not been met.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan permits the use of gym benefits toward the purchase of exercise equipment only from October 1, 2020, to December 31, 2020. The Plan's rules for coverage of gym benefits have not been met because the exercise equipment was purchased prior to October 1, 2020. Therefore, we decided that the Plan does not have to pay for exercise equipment (A9300) purchased August 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for cardiac dysrhythmia and ankle fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve skilled nursing facility services. You say that these services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and have been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). The records show you continue to make slow progress with daily skilled therapy services. There is no indication that transfer to a skilled nursing facility is required. There are no services offered at a skilled nursing facility that are not offered at an inpatient rehab facility. Medicare coverage criteria are not 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve split night sleep study.

You asked the Plan to pre-approve split night sleep study. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that split sleep studies are covered under certain circumstances.

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 split night sleep study. Our reviewer says that the services are not medically necessary. Our physician reviewer found the criteria for the INSPIRE procedure is to have a body mass index (BMI) of less than 33 as there is insufficient data on enrollees with BMI greater than 32. Sleep study would not be required as this enrollee does not qualify for the proposed procedure at the currently documented BMI. This enrollee has a BMI of greater than 32 according to the provided records. The coverage criteria are not 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 split night sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve split night sleep study.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #13 and retainer crowns (D6750) for tooth #'s 12 and 14.
You asked the Plan to pre-approve the pontic and retainer crowns. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not medically necessary.
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 pontic and retainer crowns when the services are medically necessary and reasonable. 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 pontic and retainer crowns. Our reviewer says that the pontic (D6240) for tooth #13 and retainer crowns (D6750) do not meet coverage criteria. Our physician reviewer found the coverage for a fixed bridge replacing posterior teeth does not meet the criteria for coverage unless there is documentation that a removable appliance cannot be used. Our reviewer also found that in this case there was no such documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the pontic and retainer crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #13 and retainer crowns (D6750) for tooth #'s 12 and 14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four extractions (D7140 x4).

You asked the Plan to pay for the extractions. You say that the extractions should be covered under your Platinum Dental Rider. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that the Platinum Dental Rider Benefit became effective, which is after the date these services were provided.

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. Therefore, we decided that the Plan does not have to pay for the four extractions (D7140 x4).