Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the bitewing x-rays. We decided that the Plan does not have to pay for the complete series of intraoral x-rays, panoramic x-ray, and preventive procedure.
You asked the Plan to pay for the bitewing x-rays, complete series of intraoral x-rays, panoramic x-ray, and preventive procedure. You say that you believe these services should be covered. The Plan says that the complete series of intraoral x-rays, panoramic x-ray, and unspecified preventive procedure are not covered services. The Plan also says that the bitewing x-rays are considered an integral part of a more comprehensive service and benefits are not available.
We decided that the Plan has to pay for the bitewing x-rays.
The Plan follows Medicare rules. Medicare rules say that the health plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. The contract lists bitewing x-rays as a covered benefit. The Plan denied the bitewing x-rays for being an integral part of a more comprehensive service, and benefits are not available. There is no clarification in the EOC stating that this denial reason is correct, and the Plan provided no information showing that their argument is correct. Bitewing x-rays are listed as a covered service, and you reasonably believed they would be covered. Therefore, we decided that the Plan has to pay for the bitewing x-rays.
We also decided that the Plan does not have to pay for the complete series of intraoral x-rays, panoramic x-ray, and preventive procedure.
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 complete series of intraoral x-rays, panoramic x-ray, and unspecified preventive procedure are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays, panoramic x-ray, and preventive procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (12052, 17000) provided on December 4, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE has been exceeded.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT codes 12052 and 17000 is 1. You billed 2 units for each of these codes, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (12052, 17000) provided on December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00811) provided November 30, 2020.
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The
Plan denied your request. The Plan says an explanation of benefits from the primary insurer is required before
the claim can be processed.
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 requested an
explanation of benefits from the primary insurer. As the secondary insurer, the Plan cannot be held responsible
for the anesthesia services until the primary insurer has denied the claim for these services. Therefore, we
decided that the Plan does not have to pay for anesthesia services (00811) provided November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete series of intraoral x-rays provided on January 22, 2021.
You asked the Plan to pay more for the complete series of intraoral x-rays. You say that you thought x-rays were covered. The Plan denied your request. The Plan says you are responsible for a 20% coinsurance for dental x-rays.
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, you are responsible for a 20% coinsurance for the intraoral x-ray image of the entire mouth. Therefore, we decided that the Plan does not have to pay more for the complete series of intraoral x-rays provided on January 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on September 30, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.

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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no medical history provided, other than listed diagnoses. There are no current specific or well-established clinical uses for gene variant testing for the management of known ischemic heart disease. As cardiac gene variant testing is not currently recommended for general risk stratification or useful in the management of established ischemic heart disease, it would not be considered medically reasonable or necessary.

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on September 30, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on October 16, 2020.
You asked the Plan to pay for the ambulance service and ground mileage. You say that the diagnosis is not related to hospice, and the trip is not related to hospice care. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance service and ground mileage provided on October 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trintellix.
You asked the Plan to pre-approve Trintellix. You say that the enrollee is currently stable on Trintellix. The Plan denied your request. The Plan says Trintellix to be taken at home is not covered under the Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trintellix.
Benefits for Trintellix may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and cleaning (D1110)
provided on October 16, 2020.

You asked the Plan to pay for the dental services. You say that you contacted the office prior to your
appointment. You say that you were advised these services would be covered. You say that all of your income
is accounted for. You also say that you should not have to pay since you were told these services would be
covered. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,500 for
covered dental services. The Plan says that the annual maximum benefit has been exhausted prior to processing
this claim.

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 and the services are listed as covered,
the annual maximum benefit has been exhausted.

The Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges
are your responsibility. The record shows that the plan representative advised you had a benefit maximum of
$1,500 which restarted on January 1. Therefore, we decided that the Plan does not have to pay for the periodic
oral evaluation (D0120) and cleaning (D1110) provided on October 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Sodium Hyaluronate injection (J7327) provided December 31, 2020.
You asked the Plan to waive the coinsurance for Sodium Hyaluronate injection. You say that you never had a cost share charged in the past. The Plan denied your request. The Plan says the claim has processed correctly 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a total cost share of $288.95 for Sodium Hyaluronate injection ($1,444.73 Medicare allowed amount x 20% coinsurance). Sodium Hyaluronate injection falls within the Medicare Part B prescription drugs 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 coinsurance for Sodium Hyaluronate injection (J7327) provided December 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection and a knee brace provided by a participating provider on August 24, 2020.

You asked the Plan to waive the coinsurance for an injection and a knee brace. You say that you had prior authorization for this. You say that you should not owe anything. The Plan denied your request. The Plan says the correct coinsurance has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs and durable medical equipment. 

You have been asked to pay a 20% coinsurance of the allowed amount for an injection and a knee brace. The total allowed amount is $523.77. The total amount you are being asked to pay is $104.75 ($523.77 x 20% = $104.75). An injection falls within the Medicare Part B prescription drugs benefit category and a knee brace falls within the durable medical equipment 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 coinsurance for an injection and a knee brace provided by a participating provider on August 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 13, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 services at issue in this appeal. 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 the services provided by an out-of-network provider on January 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walker (E0143) and seat attachment (E0156) provided September 20, 2020.

You asked the Plan to pay for the walker and seat attachment. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says no medical records were received from the provider to make a decision.

The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary. Therefore, we decided that the Plan does not have to pay for the walker (E0143) and seat attachment (E0156) provided September 20, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician's services for inpatient hospital care provided from
January 15, 2020, through January 19, 2020.
You asked the Plan to pay for the physician's services. You say that the medical records support that the
physician's services provided in the hospital were medically necessary. The Plan denied your request. The Plan
says that ER triage is paid, submit medical records.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically 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 pay for the physician's services. Our reviewer says
that the requested physician's services are considered medically reasonable and necessary in this case. Our
physician reviewer found that the enrollee was admitted on January 13, 2020, for urinary tract infection with
sepsis due to Escherichia coli and discharged January 27, 2020. The enrollee has a T9 spinal cord lesion with
spasticity secondary to trauma eight years ago. The enrollee presented with a white blood cell count of 11,800
and a fever of 102.6F. The enrollee was also treated for pneumonia, rhabdomyolysis and Clostridium difficile
colitis. The provided progress notes for the days in question establish that the enrollee continued to receive
medically necessary and reasonable services as defined by Medicare rules. The elements of the coverage rule
are satisfied. The requested service is recommended.
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 physician's services have been met. Therefore, we decided that the Plan has
to pay for physician's services for inpatient hospital care provided from January 15, 2020, through January 19,
2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies.
You asked the Plan to pay for incontinence supplies. You say that these supplies would be covered in a rehab center. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies or adult diapers are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 7, 2020 by a non-network provider.

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 rendered by a non-network provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. 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 laboratory services provided on December 7, 2020 by a non-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay for critical care services (99291) provided to the enrollee from October 14, 2020, to October 17, 2020 and billed under Claim A.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan stated that Claim A denied because the Plan had already paid for this service under another claim. The Plan states the NPI website shows that both providers are listed under the Surgery Taxonomy and both providers work within the same professional practice or group. The Plan states only one physician in the practice and file claim for this type of code.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group
relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met.
Therefore, we decided that the Plan does not have to pay for to pay for critical care services (99291) provided to the enrollee from October 14, 2020, to October 17, 2020 and billed under Claim A.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance angiography (MRA) of the head provided to the enrollee on September 12, 2020 and billed under Claim A.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan stated that Claim A denied because the Plan had already paid for this service under another claim. The Plan states the NPI website shows that both providers are listed as Diagnostic Radiology Specialists and both providers work within the same professional practice or group. The Plan states the correct billing of this service needed to include modifier -59 to establish a separate and distinct service was provided. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met.
Therefore, we decided that the Plan does not have to pay for magnetic resonance angiography (MRA) of the head provided to the enrollee on September 12, 2020 and billed under Claim A.