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

We decided that the Plan does not have to pay for drug testing provided on April 25, 2020.

You asked the Plan to pay for drug tests. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation
does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The record shows that the sample for this testing was taken in an
outpatient rehabilitation facility setting, therefore the Place of Service code 11 - indicating an office setting - is
not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug
tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on
April 25, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room visit (99282) collection of venous blood by venipuncture (36415) basic metabolic panel (80048) complete blood counts (CBC) (85027) radiologic examination, chest (71045) electrocardiogram (93005) provided July 7, 2020.
You asked the Plan to pay for the emergency visit. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says the claim was not billed in accordance with CMS guidelines.
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, we find that the claim was not billed in accordance with CMS guidelines. Based on this information, we decided that Medicare rules for coverage of the emergency visit have not been met. Therefore, we decided that the Plan does not have to pay for emergency room visit (99282) collection of venous blood by venipuncture (36415) basic metabolic panel (80048) complete blood counts (CBC) (85027) radiologic examination, chest (71045) electrocardiogram (93005) provided July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care, per day (99222) provided on July 4, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service is not payable as the claim was submitted untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for this service was not filed until September 21, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care, per day (99222) provided on July 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit with your primary care provider (99213) on October 30, 2020.

You asked the Plan to waive the copayment for the visit to your doctor. You say that your doctor's office did not inform you that there would be a copay for an in-person visit. The Plan denied your request. The Plan says there is a $15 copayment per visit to your primary care provider.

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 physician and practitioner services. 

You have been asked to pay a $15 copayment for the visit to your doctor. A visit to your doctor falls within the physician and practitioner services 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 visit with your primary care provider (99213) on October 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on September 23, 2020 by an out of network (OON) provider.

You asked the Plan to pay for radiology 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 by a participating provider. The Plan says that the referring provider is 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 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 radiology services provided on September 23, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says there are alternative procedures/surgeries that are available.

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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found current evidence based medical guideline and peer reviewed literature do not fully support the spinal
decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical
condition as discussed above. FDA indications include implantation of the Superion device at one or two
adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no
more than two levels, from L1 to L5. In this case, there are also multiple factors that do not meet criteria. These
include severe stenosis (as opposed to moderate), plausible segmental spinal instability, and operative
intervention may be indicated at more than two levels. Issues such as plausible osteoporosis have also not been
addressed. Superion indirect lumbar decompression would not be considered the standard of care for the
enrollee's medical condition. Therefore, Vertiflex device is not 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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable x-ray services rendered on September 5, 2020.
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 are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that a SNF must submit all Medicare claims for all services. We looked at the file and Medicare rules. The services at issue were rendered to a SNF patient and do not have separate payment outside of the SNF consolidated billing. Therefore, we decided that the Plan does not have to pay for the portable x-ray services rendered on September 5, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered on November 30, 2019.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that home health claims must report one of three Q codes. We looked at the file and Medicare rules. The file shows that the claim was not billed with the required Q code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered on November 30, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance services provided on August 31, 2020.

You asked the Plan to pay for the ambulance services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services rendered were not medically necessary.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 

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 ambulance services. Our reviewer says that the documentation supports that the services rendered were medically reasonable and necessary. Our physician reviewer found upon ambulance arrival, emergency medical services reported that the enrollee complained of dizziness and nausea since awakening. The enrollee was hemodynamically stable with stable vital signs. The electrocardiogram and exam by emergency medical services were normal. The documentation supports that the enrollee's presenting symptoms met the prudent layperson criteria for emergency care. Therefore, the enrollee met criteria for the services rendered. 

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 ambulance services have been met. Therefore, we decided that the Plan has to pay for the ambulance services provided on August 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on August 19, 2020.
You asked the Plan to pay for CxBladder testing. You say that this was medically necessary. The Plan denied
your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are
non-covered.
We looked at the file and Medicare rules. The test at issue is not covered. Based on this information, we
decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that
the Plan does not have to pay for CxBladder testing (0012M) provided on August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F2 gene analysis and F5 gene analysis (CPT Code(s):
81240 and 81241).
You asked the Plan to pre-approve the laboratory services. You say that you are requesting approval for gene
analysis services. The Plan denied your request. The Plan says the request is not medically necessary.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the laboratory services have not been met. The rules say Genetic
testing for these genes for all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular
risk assessment, are non-covered except for pregnant patients. Therefore, the services are not covered.
Therefore, we decided that the Plan does not have to pre-approve F2 gene analysis and F5 gene analysis (CPT
Code(s): 81240 and 81241).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) provided on
October 9, 2020.

You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable as they were
rendered by an out of network provider.

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.

We looked at the case file the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of these items have not been met. Specifically, the Plan contract says that hearing aids must be
obtained from an in-network provider. However, the hearing aids in this case were purchased from an
out-of-network provider. Therefore, we decided that the Plan does not have to issue reimbursement for the
hearing aids (V5261) provided on October 9, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan does not have to pre-approve the MyoPro G orthotic device (myoelectric elbow-wrist-hand-finger orthosis)(CPT Code L8702).

You asked the Plan to pre-approve orthotic device for the enrollee. You say that this item is medically necessary. The Plan denied your request. The Plan says Medical necessity has not been established. 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. Our Medical Director says that at issue is coverage for a MyoPro myoelectric elbow-wrist-hand-finger orthosis. The Maximus Physician Reviewer determined it would be medically acceptable to implement a myoelectric upper limb orthosis to assist with improved function ability in this case. The Plan requested a reopen and stated that current literature does not support that the use of a myoelectric orthosis after a stroke is any more beneficial than traditional standard therapy. The medical records show the enrollee suffered a stroke in 2006 which resulted in right sided hemiparesis. Our Medical Director says that the Plan is correct in this case. The medical records provided do not meet the requirements listed in the Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k) for Medicare coverage for the powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated (L8702). At this time the requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical condition/function of hemiparesis after stroke than any available standard therapy. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro G orthotic device (myoelectric elbow-wrist-hand-finger orthosis)(CPT Code L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 1 to October 16, 2020, by an out of network provider.
You asked the Plan to pay for the medical services. You say that the requested services were medically necessary. The Plan denied your request. The Plan says rules for payment have not been met.
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 medical services provided on October 1 to October 16, 2020, by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 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 you were admitted for surgical repair of a hip fracture after a fall. Your medical conditions are stable. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support that you require physical therapy and occupational therapy, the documentation does not support that you require an intensive rehabilitation therapy program. Your care needs can be met at a lower level of care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator purchased on July 27, 2020.
You asked the Plan to pay for the oxygen concentrator. You say that with your health problems, you cannot use
a used concentrator. You also say that you were advised that you would be reimbursed for this item. The Plan
denied your request. The Plan says the item received is not a covered benefit when purchased.
The Plan must follow Medicare rules. The rules say that enrollees must rent durable medical equipment.
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 oxygen concentrator have not been met. Therefore, we decided that the Plan
does not have to pay for the oxygen concentrator purchased on July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 00530 provided on October 19, 2020.
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested were billed incorrectly.
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 00530 is anesthesia for permanent transvenous pacemaker insertion. We find that CPT code 00530 is not supported in the medical record. Specifically, this code was billed with QZ and QS modifiers (monitored anesthesia care service). Services are not covered when they are billed with modifier QZ and the same service had been previously allowed with modifier QY, QK, or AD indicating that the procedure was supervised/medically directed under different provider ID for the same date of service. This service with modifiers AD and QS has been previously processed by the plan. If there is some sort of medical supervision by the anesthetist for a qualified non-physician anesthetist, then appropriate modifiers must be appended to claim the payment. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 00530 provided on October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric service provided on July 22, 2019.
You asked the Plan to pay for the psychiatric service. You say that you did not receive proper notice of the enrollee's benefit determination. The Plan denied your request. The Plan says the claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the psychiatric service was not filed until September 8, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the psychiatric service provided on July 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a negative pressure wound therapy pump (NPWT).
You asked the Plan to pre-approve the pump. You say that this is medically necessary. The Plan denied your
request. The Plan says the biopsy report shows cancer left in the wound.
The Plan must follow Medicare rules. Medicare rules say that NPWT is not covered if there is cancer present in
the wound.
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 pump. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is residual cancer (sarcoma) in the wound. This is one of the exclusion criteria.
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 pump have not been met. Therefore, we decided that the Plan does not have
to pre-approve a negative pressure wound therapy pump (NPWT).