Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan does not have to pre-approve needle electromyography studies (EMG) with CPT code 51785 provided to the enrollee on March 13, 2020.
You asked the Plan to pre-approve needle electromyography studies (EMG) with CPT code 51785. You say that this claim should be paid. The Plan denied your request. The Plan says 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 criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for needle electromyography (EMG) of the anal or urethral sphincter. The Maximus Physician Reviewer determined that the medical records support the billing of CPT code 51785. Our physician reviewer found that the intraoperative monitoring report indicated that spontaneous EMG recording was performed at the iliopsoas, quadriceps and anal sphincter. The Plan argues that the intraoperative neuromonitoring report did not reflect that any diagnosis was attempted. The plan maintains that this was not a diagnostic test, rather it was a monitoring procedure during surgery in which no diagnosis is reported or attempted. Our Medical Director reviewed the medical records. The enrollee was seen in consultation for evaluation of lumbar and thoracic stenosis. The enrollee had symptoms of thoracic myelopathy from T11-12 stenosis and spinal cord compression, as well as neurogenic claudication. On March 13, 2020 the enrollee underwent T11-12 laminectomy with the use of intraoperative neuromonitoring. Our Medical Director says the Plan is correct in this case. The documentation does not support that a urodynamic procedure on the bladder was performed in this case. The documentation supports that the procedure was an intraoperative neuromonitoring procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography studies (EMG) with CPT code 51785 have not been met. Therefore, we decided that the Plan does not have to pre-approve needle electromyography studies (EMG) with CPT code 51785 provided to the enrollee on March 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe surgical consult to be provided by an out of network (OON) provider.You asked the Plan to pre-approveOON surgical consult. You say that that the in-network provider is not qualified to safely perform surgery.The Plan denied your request. The Plan says the requestedservices 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 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 provider at issue in this case is not a network provider with the Plan. 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 OON surgical consult. Our reviewer says that the criteria for coverage of out-of-network services have not been met. Our physician reviewer found the Plan is only obligated to authorize out-of-plan care when in-plan care is not available. That is not the case here. There is a qualified in-network provider who can provide the services requested.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of OON surgical consult have not been met. 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 OON surgical consult.Therefore, we decided that the Plan does not have to pre-approvethe surgical consult to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids.

You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says out-of-network hearing aids are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan does not pay for hearing aids ordered through providers other than the Plan's network hearing providers. 

We looked at the file and the Plan's rules. The hearing aids in question were provided by an out-of-network provider. Out-of-network hearing aids are not covered. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services (97813, 97814) provided June 25, 2020.
You asked the Plan to pay for the acupuncture services. You say that you are submitting the medical records with this letter to show medical necessity of the services given. The Plan denied your request. The Plan says his provider is not supervised by any physician, PA, or NP/CNS.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, acupuncture services provided in a chiropractor's office or in a SPA setting is not covered. Therefore, we decided that the Plan does not have to pay for the acupuncture services (97813, 97814) provided June 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the Echocardiography, transthoracic, real-time with image documentation (2D) (93351) provided September 14, 2020.
You asked the Plan to waive the deductible for the echocardiogram. You say that your deductible was previously met. The Plan denied your request. The Plan says your cost share was calculated correctly.
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 a $750 deductible. It also says that there is a $160 copayment for each Medicare-covered radiological diagnostic service, not including X-rays, performed in a physician's office or at a freestanding facility. The item or service you asked the Plan to waive the deductible for falls within the benefit category Other outpatient diagnostic tests - Radiological diagnostic services, not including x-rays. The Plan provided documentation that a previous claim was adjusted and credited back to your deductible. Therefore, at the time of the service, you had $268.22 remaining in your deductible. The Plan asked you to pay a total cost-share of $428.22 ($268.22 deductible + $160 copayment = $428.22). The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $160 copayment for Other outpatient diagnostic tests - Radiological diagnostic services, not including x-rays after the $750 deductible is met. This cost sharing is a contractual obligation that had not been met at the time the Echocardiography, transthoracic, real-time with image documentation (2D) was received on September 14, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the Echocardiography, transthoracic, real-time with image documentation (2D) (93351) provided September 14, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician certification for home health billed for services.

You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says 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 G0180 is physician certification for Medicare-covered
home health services under a home health plan of care (patient not present), including contacts with home
health agency and review of reports of patient status required by physicians to affirm the initial implementation
of the plan of care that meets patient's needs, per certification period.

We looked at the file and the rules. We find that CPT code G0180 is not supported in the medical record. Based
on this information, we decided that Medicare rules for coverage of the billed services have not been met.
Therefore, we decided that the Plan does not have to pay for the physician certification for home health billed
for services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection services (J7321, 20610) provided by a specialist from July 30, 2020 to August 13, 2020.
You asked the Plan to waive the copayment for the injection services. You say that you were told you did not owe anything at the time of the service. The Plan denied your request. The Plan says physician or practitioner services, such as an injection, are subject to a $30 copayment per service when provided by a specialist.
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 $30 copayment for physician and practitioner services provided by a specialist. You have been asked to pay a $30 copayment for the injection services. Injection services fall within the physician and practitioner services benefit category. The services in question were provided by an orthopedic specialist. 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 injection services (J7321, 20610) provided by a specialist from July 30, 2020 to August 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the inpatient hospital stay provided from August 31, 2020, to September 1, 2020.
You asked the Plan to waive the coinsurance for the inpatient hospital stay. You say that you were sent a bill even though your Explanation of Benefits says you are not responsible for this amount. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% per stay for in-network Medicare-covered hospital stays. You have been asked to pay $1,001.27 which is 20% of the allowed amount for the inpatient hospital stay. The allowed amount is $5,006.34. ($5,006.34 x 20% = $1,001.27). The inpatient hospital stay falls within the "Inpatient hospital care" 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 the inpatient hospital stay provided from August 31, 2020, to September 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Liquid FoundationOne testing for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental and investigational for this indication in the absence of any histological tissue biopsy.
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 testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was diagnosed with metastatic liver cancer in the fall of 2020. Testing specifically related to her liver cancer, for which associated therapies are known, is medically necessary and reasonable. Panel testing, inclusive of testing that is not related to liver cancer or for which there are no associated therapies, is not medically necessary or reasonable. The documentation does not support that the requested panel testing is medically necessary or reasonable. 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 pre-approve Liquid FoundationOne testing for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from January 23, 2020, to January 25, 2020.
You asked the Plan to pay for the self-administered drugs. You say that these medications were given to you as an inpatient in the hospital. You say that you had no idea you would be charged for them as you have drug coverage. You also say that you would have brought your own medications with you if you had known that you would be charged for them. The Plan denied your request. The Plan says the drugs that you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
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 pay for the self-administered drugs provided in an outpatient setting from January 23, 2020, to January 25, 2020.
Benefits for the self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator (E1390) purchased June 12, 2020.
You asked the Plan to pay for the oxygen concentrator. You say that instead of renting an oxygen concentrator you chose to purchase one because you believed it would be cheaper. The Plan denied your request. The Plan says oxygen equipment that is purchased is not covered.
The Plan must follow Medicare rules. Medicare rules say that the Plan may not pay for oxygen equipment that is purchased on or after June 1, 1989. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator (E1390) purchased June 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit provided on July 8, 2020.
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for domiciliary or rest home visit provided on July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal cord stimulator (SCS) trial.

You asked the Plan to pre-approve spinal cord stimulator trial. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are only covered for certain indications.

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 spinal cord stimulator trial. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain. The enrollee is taking Gabapentin, Motrin, Tizanidine, Norco and Tramadol for pain. The request refers to physical therapy but there is no discussion or notes from physical therapy included in the documents submitted. The enrollee does not have an evidence based indication for a SCS trial. There are a multitude of other therapies that have not been trialed for this enrollee. Therefore, the enrollee does not meet criteria for the requested services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal cord stimulator trial have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal cord stimulator (SCS) trial.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the hernia repair (49507) provided on June 17, 2020.
You asked the Plan to pay for the hernia repair. You say that you would like reconsideration because these
services were ordered by the surgeon. The Plan denied your request. The Plan says certified surgical
technicians are not recognized for payment by Medicare.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP,
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for the hernia repair (49507) provided
on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 10, 2019.
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 medical services provided to the enrollee by an out-of-network provider on December 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray services you had.

You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the 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 $65 copayment for basic radiological services.

Review of the file shows that you were provided x-ray services. You have been asked to pay a $65 copayment for the x-ray services. The x-ray services 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-ray services you had.