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

We decided that the Plan does not have to pay for the laboratory services provided on February 24, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from
September 30, 2020 through May 27, 2021. The Plan says, per Medicare guidelines, the provider must bill
Original Medicare for the services provided on February 24, 2021.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the laboratory services provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on March 29, 2021.

You asked the Plan to waive the copayment for these services. You say that you were charged for a virtual follow-up visit. The Plan denied your request. The Plan says the copayment was 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 $35 copayment for services obtained from a specialist.

Review of the file shows that you received specialist services on March 29, 2021. You have been asked to pay a $35 copayment for these services. These services fall within the services obtained from a specialist 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 specialist services rendered on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 19, 2020 or the cataract removal provided on September 9, 2020.

You asked the Plan to pay for the office visit or cataract removal. You say that you have no other insurance. The Plan denied your request. The Plan says from the dates of May 1, 2019, to September 30, 2020 you had other insurance.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has tried to get the Evidence of Benefits from the other insurance and was not able to reach them. As the secondary insurer, the Plan cannot be held responsible for the physician services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the office visit provided on February 19, 2020 or the cataract removal provided on September 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left lumbar RFA.

You asked the Plan to pre-approve destruction by neurolytic agent (64635) and destruction by neurolytic agent, each additional facet joint (64636). You say that the enrollee has had only one left RFA within 12 months, one was laser ablation. The Plan denied your request. The Plan says the records show the enrollee had two sessions of RFA within the past 12 months.

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 destruction by neurolytic agent (64635) and destruction by neurolytic agent, each additional facet joint (64636). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found both previous procedures are the same modality. The request exceeds the limits of the LCD and therefore, the request is considered not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. The record shows the enrollee had RFA of the lumbar spine on November 30, 2020 and March 1, 2021. Based on this information, we decided that Medicare rules for coverage of destruction by neurolytic agent (64635) and destruction by neurolytic agent, each additional facet joint (64636) have not been met. Therefore, we decided that the Plan does not have to pre-approve left lumbar RFA.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-rays provided on February 2, 2021, February 9, 2021 and February 16, 2021
You asked the Plan to waive the copayment for the x-rays. You say that you should only be responsible for specialist office visit copayments. The Plan denied your request. The Plan says you were charged the copayments 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 $70 copayment for Outpatient Diagnostic Tests. You have been asked to pay a $70 copayment for the x-rays. the x-rays fall 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-rays provided on February 2, 2021, February 9, 2021 and February 16, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous device procedure.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (22867). You say that the enrollee needs this device for pain relief. The Plan denied your request. The Plan says laminectomy is approved but the device is not proven to be helpful for the enrollee's health problem.

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, without fusion, including image guidance when performed, with open decompression, lumbar; single level (22867). 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 high failure rates with similar devices have been demonstrated. 

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, without fusion, including image guidance when performed, with open decompression, lumbar; single level (22867) have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous device procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 test (CPT code 81201, 81293, 81321, 81301) provided to the enrollee on March 14, 2021.
You asked the Plan to pay for the laboratory testing. You say that this should be covered. The Plan denied your request. The Plan says see the MolDx policy articles A57867 and A57910 which note the appropriate CPT codes with which to request payment for this service.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. This request represents apparent claim unbundling and is not allowed by CMS. Therefore, we decided that the Plan does not have to pay for Guardant360 test (CPT code 81201, 81293, 81321, 81301) provided to the enrollee on March 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (CPT code 80307) provided to the enrollee on January 25, 2021, by an out-of-network provider.
You asked the Plan to pay for the drug test. 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 the drug test (CPT code 80307) provided to the enrollee on January 25, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided the Plan does not have to pay for dental services (D0220 and D9310) provided on January 22,
2021.

You asked the Plan to pay for these dental services. You say that these dental services should be covered by the
Plan. The Plan denied your request. The Plan says the dental services provided are not covered under the dental
benefit. Maximus overturned the Plans denial administratively because the Plan did not submit the dental
contract for review. The Plan requested a reopen and provided a copy of the dental benefit documentation.

The Plan is correct in this case. Medicare does not cover dental services. 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, code D0220 was not available for
coverage at the time of service due to frequency limitation and code D9310 is not a covered benefit. Therefore,
we decided that the Plan does not have to pay for dental services provided on January 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for bone and/or joint imaging, whole body (78306) and radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s), tomographic (SPECT) (78832) provided March 30, 2021.

You asked the Plan to waive the copayment for the diagnostic service. You say that you get the same procedure once every 3 months and never have been billed a separate co-insurance. The Plan denied your request. The Plan says the claim was processed with the correct cost share applied per the Evidence of Coverage.

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 $110 copayment for Medicare covered diagnostic radiology services and 20% coinsurance for therapeutic radiological services and supplies.

You have been asked to pay $325.21 ($110.00 + $215.21) for the diagnostic service. The diagnostic service 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 bone and/or joint imaging, whole body (78306) and radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s), tomographic (SPECT) (78832) provided March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Hydrogel Spacing (SpaceOAR) procedure.

You asked the Plan to pre-approve the SpaceOAR. You say that you need to have this petition installed so that you can start your radiation therapy and treat your prostate cancer. The Plan denied your request. The Plan says the records do not support that the criteria for coverage have been met.

The Plan follows Medicare rules. Medicare rules say that PEG hydrogel is covered once for patients who meet specific coverage criteria.

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 SpaceOAR. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has T3N1, Stage IV disease and would not have been eligible for the randomized study mentioned in the clinical records. No consensus guidelines or prospective study supports the need for the use of hydrogel spacers in patients with Stage IV disease. Importantly with this T and N stage of prostate cancer, the LCD 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 the SpaceOAR have not been met. Therefore, we decided that the Plan does not have to pre-approve a Hydrogel Spacing (SpaceOAR) procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network provider.

You asked the Plan to pre-approve the office visits. You say that you have seen this provider since 2018 and want to continue because you have a good relationship with the provider. The Plan denied your request. The Plan says there are providers available in-network that can and are ready to provide the care at this time.

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 the office visits to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a medical eye exam (92014), an ophthalmoscopy (92201) and an imaging of the eye (92134) provided on February 10, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a medical eye exam, an ophthalmoscopy and imaging. You say that the member's condition required immediate evaluation. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 a medical eye exam (92014), an ophthalmoscopy (92201) and an imaging of the eye (92134) provided on February 10, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee on October 7, 2019.

You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the documentation does not support that the services were rendered in the enrollee's private residence. To bill these codes, the physician must be physically present in the enrollee's home. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee on October 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomics panel provided on December 16, 2020.

You asked the Plan to pay for the testing services. You say that the tests were specifically requested by the enrollee's physician. 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. Only one HCPCS/CPT code with one unit of service may be reported for the procedure performed. 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 panel provided on December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on November 24, 2020.

You asked the Plan to pay for an office visit. You say that this was billed correctly because the enrollee was evaluated for a toothache. The Plan denied your request. The Plan says this is not a covered dental 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. Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on November 24, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (99233, 99239) provided from December 7, 2020, to December 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed services cannot be verified.
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 99233 is "Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit." The CPT Code Manual Definition of code 99239 is "Hospital discharge day management; more than 30 minutes." We asked our coding 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 the services. Our reviewer says that the use of codes 99233 and 99239 is supported by the records provided. Our coding reviewer found that for code 99233, the documentation supports 2 of 3 key components required for this level of service. For code 99239, the documentation submitted supports a hospital discharge evaluation and management of more than 30 minutes. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for the services (99233, 99239) provided from December 7, 2020, to December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
You asked the Plan to pre-approve a pneumatic compression device. You say that please look at your claim again to determine that this was a medical necessity because of your heart condition so therefore should be covered. The Plan denied your request. The Plan says this device is not covered.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 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, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).