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

We decided that the Plan does not have to pay for train of four testing (95999) provided on January 7, 2019.
You asked the Plan to pay for train of four testing. You say that this should be paid. The Plan denied your request. The Plan says the medical records do no support the use of this code.
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 95999 is not supported in the medical record. Specifically, unlisted CPT code 95999 is not supported for train of four testing. According to CPT rules, train of four is included in other intraoperative neuromonitoring procedures and is not reported separately. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on January 7, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for the diagnostic mammogram rendered to you on June 26, 2018.You asked the Plan to waive the copayment forthese services. You say that you should have no copayment.The Plan denied your request. The Plan says that the copayment was applied 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 enrollees must pay a $50 copayment for diagnostic services.The Plan says you must pay a $150 copayment for these services. Based on the Plan contract, however, you cannot be asked to pay more than a $50 copayment for these services. Therefore, we decided that the Plan has to waive the copayment forthe diagnostic mammogram rendered to you on June 26, 2018
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes L1812, L2795, and 20611 provided on July 18, 2019.
You asked the Plan to pay for CPT codes L1812, L2795, and 20611. 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 supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code L1812 is Knee orthosis, elastic with joints, prefabricated, off-the-shelf and code L2795 is Addition to lower extremity orthosis, knee control, and full kneecap. We find that CPT codes L1812 and L2795 are not supported in the medical record. Specifically, the documentation submitted did not include documentation that these items were dispensed to the enrollee, therefore the billed services cannot be verified. The CPT Code Manual definition of code 20611 is Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting. We find that CPT code 20611 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of permanently recorded images, therefore the billed service cannot be verified.
Based on this information, we decided that Medicare rules for coverage of CPT codes L1812, L2795, and 20611 have not been met. Therefore, we decided that the Plan does not have to pay for CPT codes L1812, L2795, and 20611 provided on July 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit provided on August 15, 2019.You asked the Plan to pay forthe annual wellness visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the enrollee had exceeded their benefit limit for this service.The Plan must follow Medicare rules. Medicare rules say that an annual wellness visit is covered once every 12 months.Review of the file shows that the enrollee had an annual wellness visit on August 15, 2019.The enrollee previously had an annual wellness visit on October 8, 2018 for which was plan approved and paid. The visit on August 15, 2019 was less than 12 months from the enrollee's prior annual wellness visit.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the annual wellness visit have not been met.Therefore, we decided that the Plan does not have to pay forthe annual wellness visit provided on August 15, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wound repair services coded 12052 and the excision services coded 11643 provided on August 29, 2019.You asked the Plan to pay forthe wound repair services and the excision services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 12052 is repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm.The CPT Code Manual definition of code 11643 is excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cm.We find that CPT codes 12052 and 11643 are not supported in the medical record. Specifically, thesubmitted medical records do not include procedure documents to support that repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm was performed.Therefore, code 12052 cannot be verified. Also, the submitted medical records do not include procedure documentation to support that excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cm was performed.Therefore, code 11643 cannot be verified. Based on thisinformation, we decided that Medicare rules for coverage of the wound repair services and the excision services have not been met. Therefore, we decided that the Plan does not have to pay forthe wound repair services coded 12052 and the excision services coded 11643 provided on August 29, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe stress test rendered to you on July 25, 2019.You asked the Plan to waive the deductible forthese services. You say that there should be no cost for the procedure.The Plan denied your request. The Plan says the deductible was applied 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 $975 plan deductible for your in-network and out-of-network Medicare-covered services. The item or service you asked the Plan to waive the deductible for falls within the diagnostic imaging benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $975 plan deductible for your in-network and out-of-network Medicare-covered services. This cost sharing is a contractual obligation that had not been met at the time these services were received on July 25, 2019. Therefore, we decided that the Plan does not have to waive the deductible forthe stress test rendered to you on July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit services you provided to the enrollee on May 29, 2019.You asked the Plan to pay forthe services. You say that you feel that these services are medically necessary.The Plan denied your request. The Plan says you are out-of-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 has network providers available who can provide 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 forthe office visit services you provided to the enrollee on May 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection procedure for a sacroiliac joint (G0260) provided on June 4, 2019.You asked the Plan to waive the copayment foran injection procedure. You say that you should not be responsible to pay the $275 copayment to the provider. You were advised that when you received service  for the same procedure, you only had a copayment for an office visit. You cannot afford to pay this copayment and are asking the health plan to reconsider this charge.The Plan denied your request. The Plan says outpatient surgeryservices have a $275 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 $275 copayment for outpatient surgery. You have been asked to pay a $275 copayment for an injection procedure. This servicefalls within the outpatient surgery benefit categoryin an ambulatory or hospital setting. 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 foran injection procedure for a sacroiliac joint (G0260) provided on June 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe needle electromyography services provided on April 25, 2019.You asked the Plan to pay forthe needle electromyography services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 95886 is Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure).We find that CPT code 95886 is not supported in the medical record. Specifically, the documentation submitted did not indicate that needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels; therefore, the billed service cannot be verified. The submitted documentation indicates needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited was performed. Based on this information, we decided that Medicare rules for coverage of the needle electromyography services have not been met.Therefore, we decided that the Plan does not have to pay forthe needle electromyography services provided on April 25, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to waive the copayment for the comprehensive eye exam diagnostic and refraction services provided July 10, 2019.You asked the Plan to waive the copayment for the vision services. You say that you are requesting review of the invoice showing you owe $100 for services.The Plan denied your request. The Plan says that the correct cost share was applied according the plan benefits with a $40 specialist's copay and the refraction of $45.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 enrollees must pay $40 copayment for specialist's office visit and $0 routine eye exam includes refraction for Vision care. The Plan says you must pay $85 which included $40 specialist's copay and $45 for refraction for the vision services. Based on the Plan contract, however, you cannot be asked to pay more than $40 copayment for specialist's office visit. The plan contract on page 85 says there is $0 copayment for routine eye exam includes refraction. The refraction is included with the eye exam per the plan benefits.Therefore, we decided that the Plan has to waive $45 copayment for the refraction services provided on July 10, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forEmergency Clinic services (99284, 72040, 73502) provided May 25, 2019 by "the provider". You asked the Plan to pay forthe emergency clinic services. You say that the services were medically necessary.The Plan denied your request. The Plan says this type of provider is not eligible for payment under Medicare rules.The Plan must follow Medicare rules. Medicare rules say that that Medicare covers services in freestanding emergency departments only if the emergency clinic is affiliated with a hospital.We looked at the file and Medicare rules. The clinic that provided the services at issue has no hospital affiliation and is not eligible for Medicare enrollment. Based on this information, we decided that Medicare rules for coverage of the emergency clinic services have not been met.Therefore, we decided that the Plan does not have to pay forEmergency Clinic services (99284, 72040, 73502) provided May 25, 2019 by "the provider".
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 17, 2018 through October 18, 2018.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from October 17, 2018 through October 18, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fordialysis services provided by "the provider" on July 30, 2019.You asked the Plan to waive the coinsurance fordialysis services. You say that you think it is unfair to be charged this amount, and were not told about this cost.The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.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 in-network dialysis services at a dialysis center.The allowed amount of this claim is $251.05, resulting in a coinsurance obligation of $50.21.You have been asked to pay 20% coinsurance for dialysis services. Dialysis services fall within the Services to Treat Kidney Disease 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 fordialysis services provided by "the provider" on July 30, 2019.Your complaint regarding not being told about the cost-share for these services is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at the current facility.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. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for end-stage heart failure. The enrollee was deemed to not be a candidate for a heart transplant. She did receive valve surgery and a left ventricular assist device. The enrollee's hospital course has been complicated by respiratory failure, renal failure and subarachnoid hemorrhages. The enrollee has received a tracheotomy and remains on a ventilator. Her long-term prognosis appears to be poor. It is unclear that she can be weaned from a ventilator or be decannulated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) levelof care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. In this case, the member is mostly moderate to max assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period of time.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bevacizumab injection provided on June 7, 2019.You asked the Plan to pay forthe bevacizumab injection. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not medically necessary.The Plan follows Medicare rules. Medicare rules say that bevacizumab injection is 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 pay for the bevacizumab injection. Our reviewer says that the documentation does not support that the services rendered were medically reasonable or necessary. Our physician reviewer found the enrollee was seen in the outpatient clinic on June 7, 2019 for a follow-up visit after hospitalization. At that time, it was documented that the enrollee had a "history of GI bleeding, which has been more controlled after initiation of Avastin." The enrollee received a dose of Avastin that day, per the research protocol.Bevacizumab has been used with some success in case reports and in small case series for the treatment of refractory bleeding from small bowel angiodysplasia. The cause of the enrollee's gastrointestinal bleeding is not documented in the case file; the Assessment/Plan includes "Bleeding Gastrointestinal Obscure". The documentation does not support that Bevacizumab was medically reasonable and necessary for the enrollee in this case, as the enrollee does not have a medically-accepted indication for this drug. 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 bevacizumab injection have not been met.Therefore, we decided that the Plan does not have to pay forthe bevacizumab injection provided on June 7, 2019.