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

We decided that the Plan does not have to waive the coinsurance for the Methylprednisolone injection (J1030).

You asked the Plan to waive the coinsurance for the drug services. You say that you believe you are being overcharged or balance billed by the provider. The Plan denied your request. The Plan says they have filed a grievance for a separate investigation, but Medicare Part B drugs require 20% coinsurance, which 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 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay $2.35 for the drug services. The Plan's allowed amount for this service is $11.76 ($11.76 x 20% = $2.35). 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 the Methylprednisolone injection (J1030).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a follow-up office visit provided by a participating provider.

You asked the Plan to waive the copayment for a follow up office visit. You say that you were told that you would not be charged for this. The Plan denied your request. The Plan says the correct copayment 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 $35 copayment for physician/practitioner services/in-network/specialist.

You have been asked to pay a $35 copayment for a follow up office visit. Follow-up office visits are subject to a copayment. A registered nurse is considered a specialist; therefore, the correct copayment has been applied. A follow up office visit falls within the physician/practitioner services/in-network/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 a follow-up office visit provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745).

You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the records do not support the billed item in this case.

The Plan must follow Medicare rules. Medicare rules say that records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for determining that an item is reasonable and necessary. Additionally, coverage of NMES to treat muscle atrophy is limited to the treatment of disuse atrophy where nerve supply to the muscle is intact.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Specifically, Medicare rules state that coverage of NMES to treat muscle atrophy is limited to the treatment of disuse atrophy where nerve supply to the muscle is intact. The medical records provided do not indicate that the neuromuscular stimulator is being prescribed for that issue or that there was an intent to order it for a specific reason. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator (E0745).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0427).

You asked the Plan to pay for the ambulance services. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says this claim is not separately 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 code A0427 is not supported in the medical record. Specifically, the patient was an inpatient at the time services were provided. Ambulance transport between facilities during an inpatient stay is not separately payable. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0427).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure.

You asked the Plan to pay for the preventive procedure. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not covered.

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 preventive procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam and periapical x-rays.

You asked the Plan to pay for these services. You say that you needed your tooth extracted. The Plan denied your request. The Plan says the exam exceeded the benefit limit and the periapical x-rays were paid up to the annual maximum amount.

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 one limited oral exam per year and unlimited periapical x-rays. Services from an out-of-network provider are covered at the maximum allowable charge.

We looked at the file and the Plan's rules. The file shows that you previously had a limited oral exam that was covered by the Plan. The exam exceeded the limit of one covered exam per year. The periapical x-rays were paid at the maximum allowable rate for an out-of-network provider. Further payment is not covered by Medicare or your supplemental dental benefit. Therefore, we decided that the Plan does not have to pay for the limited oral exam and periapical x-rays.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99284).

You asked the Plan to pay for the emergency room services. You say that the services were medically
necessary. The Plan denied your request. The Plan says a required modifier was not included on the claim.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT code 99284 is not supported in the medical record. Specifically, Medicare requires that
modifier 25 always be appended to the emergency department evaluation and management code (99281-99285)
when provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical
procedure. Modifier 25 was not included. Based on this information, we decided that Medicare rules for
coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have
to pay for emergency room services (99284).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services provided to the enrollee.

You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your request. The Plan says the enrollee's needs did not require inherently complex care with a registered nurse.

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 the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there were no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment.

You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that when conducting a review of a covered DME item ordered by a physician, the Plan shall ensure that the physician saw the enrollee (including through the appropriate use of telehealth) and conducted a face-to-face assessment.

We looked at the file and Medicare rules. The file does not contain documentation showing that the face-to-face encounter included information supporting the enrollee was evaluated or treated for a condition that supports the DME ordered. The file does not document that the face-to-face encounter was made prior to the written order. Therefore, we decided that the Plan does not have to pay for the durable medical equipment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99214).

You asked the Plan to waive the copayment for the office visit. You say that this was your routine annual
wellness visit with your gynecologist and should be covered with a $0 copayment. The Plan denied your
request. The Plan says this service was not billed as a routine wellness visit. Medical records were provided
that show that pre-existing conditions were addressed over the course of this visit. Non-routine office visits
with your primary care provider are subject to a $15 copayment.

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 $15
copayment for an office visit with your primary care provider.

You have been asked to pay a $15 copayment for the office visit with a primary care provider. This visit was
not billed as an annual wellness exam and included services to address pre-existing conditions. When you have
specific conditions or diseases to address during an office visit, it is not considered routine. 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 office visit (99214).

Your complaint about confusion and possible negative interactions with the Plan's customer service department
is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided by an out of network (OON) provider.

You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 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. 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 specialist services provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Space OAR (55874, A4649) for the enrollee.

You asked the Plan to pre-approve a Space OAR (55874, A4649). You say that the Space OAR is medically necessary for the enrollee. The Plan denied your request. The Plan says the Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct LCD criteria.

Our Medical Director looked at the case file and the reopen request. Our Medical Director says that at issue is coverage for Space OAR Hydrogel. The Maximus Physician Reviewer determined that a recent meta-analysis showed significantly fewer rectal toxic effects and higher bowel-related quality of life in late follow-up. This patient has rheumatoid arthritis which increases his risk of adverse effects from radiation. Based on this information, it was determined that Medicare rules for coverage of a Space OAR were met. The Plan requested a reopen and stated that the records show the enrollee is in an unfavorable intermediate risk group, which is outside the inclusion criteria of the LCD. The Plan also notes that, in regard to the rheumatoid arthritis history, the enrollee has been in remission for 4 years. The Plan also cites a clinic note stating, "Concern is that by inserting spacer gel, we may render arch interference for the HDR procedure." Our Medical Director reviewed the medical records. The records show the enrollee is a 69-year-old man with unfavorable intermediate risk prostate cancer. Our Medical Director concluded that the Plan is correct in this case. The documentation does not support that the required coverage criteria established by LCD L37485 have been met in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Space OAR (55874, A4649) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Space OAR (55874, A4649) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the blended drugs and billed under code J3490.

You asked the Plan to pay for the services as billed. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says because a nutria-pharmaceutical blend was administered; each component of the blend cannot be billed separately. The Plan states that the appropriate unit for the nutri-pharmaceutical blend has already been processed on the billed date of service; therefore, the billed code cannot be verified. The Plan states multiple attempts were made to contact the provider to obtain additional information regarding the medication and dosage administered, however no response was received.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed because the drug components are not allowed to be billed separately. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for the blended drugs and billed under code J3490.
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 treatment 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection (CPT code J7321), for the enrollee.

You asked the Plan to pre-approve the medication. You say that the enrollee has a history of lumbar radiculopathy and left hip osteoarthritis with recurrent left anterior deep hip pain. You state the enrollee has been using Tylenol with some improvement in symptoms. The Plan denied your request. The Plan says Supartz is not covered by Medicare B because this drug is not FDA approved to treat osteoarthritis of hip and is not listed in the CMS approved compendia.

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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medication have not been met. The package insert and usage instructions indicate this drug is only used for the knee. Your request is for the hip. Therefore, we decided that the Plan does not have to pre-approve hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection (CPT code J7321), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider.

You asked the Plan to waive the copayment for an ultrasound. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment 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 $125 copayment for outpatient diagnostic tests.

You have been asked to pay a $125 copayment for an ultrasound. The correct copayment has been applied to the services that were provided. An ultrasound falls 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 an ultrasound provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee scooter provided on September 11, 2020.
You asked the Plan to pay for the knee scooter. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the knee scooter provided on September 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

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 there is no evidence of an established
relationship between the member and the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.

The file does not contain documentation of an established relationship between the enrollee and the ordering
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve ablation for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says investigational procedures are not a covered benefit.

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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered and experimental and investigational procedure, as there are ongoing clinical trials for this procedure. Additionally, cooled radiofrequency ablation is not an accepted method of ablation by Medicare.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve ablation for the enrollee.