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

We decided that the Plan does not have to waive the coinsurance for the ranibizumab injection (J2778),
provided on February 1, 2021.
You asked the Plan to waive the coinsurance for the ranibizumab injection. You say that the service should be
covered. The Plan denied your request. The Plan says the cost share 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 a 20%
coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance for the ranibizumab injection. This falls within the Medicare
Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the
ranibizumab injection (J2778), provided on February 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pneumatic compression services (E0651, E0667) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve pneumatic compression services. You say that these services are medically necessary.The Plan denied your request. The Plan says the Plan will cover these services if they are obtained from an in-network provider.

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 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 has specifically said that they will provide coverage for the pneumatic compression device if purchased from an in-network provider. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve pneumatic compression services (E0651, E0667) 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 implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments (D6080 x 2) provided on March 11, 2021.

You asked the Plan to pay for the dental services. You say that your dentures were loose. You say that you had the little rubber bands replaced. You also say that these services were very necessary. The Plan denied your request. The Plan says this service is not listed as a covered service.

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 implant maintenance services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments (D6080 x 2) provided on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thirty (30) office visits (99214) with a cardiologist, to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the office visits. You say that you are out of your service area during the summer season and because of your medical condition, your primary care physician recommended you see a cardiologist during this time. The Plan denied your request. The Plan says 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 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 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve thirty (30) office visits (99214) with a cardiologist, to be provided by an out of network (OON) 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the patient is motivated to improve and will tolerate the three hours of therapy required of acute rehabilitation. The Plan denied your request. The Plan says that the enrollee has no complex medical needs that require intensive rehabilitation.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a stroke. The
enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has right knee pain secondary to osteoarthritis. There is no documentation of a diagnostic evaluation, physical exam, differential diagnosis or prior conservative measures attempted. The clinical documentation provided was a procedure note. The documentation does not support that Orthovisc is safe and effective and medically necessary for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve Orthovisc.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have a diagnosis of knee osteoarthritis. You have not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be less effective or unable to be prescribed; therefore, Synvisc-One is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural steroid injections for the enrollee,
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that it has been verified with the providers office that this member has not had any imaging of the lumbar spine.
The Plan must follow Medicare rules. Medicare rules say that in order for lumbar epidural steroid injections to be covered, plain films to rule out red flag condition are required. We looked at the file and Medicare rules. There is no imaging of the enrollee's lumbar region, including plain films included in the file. 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 pre-approve lumbar epidural steroid injections for the enrollee,
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a standard wheelchair (K0001) and sales tax (S9999), provided on January 1, 2021, by a non-participating provider.
You asked the Plan to pay for a wheelchair and sales tax. You say that the item is medically necessary. The Plan denied your request. The Plan says Medicare only covers durable medical equipment (DME) from DME suppliers that are enrolled in Medicare.
The Plan must follow Medicare rules. Medicare rules say make sure your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers must meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers are not enrolled, Medicare will not pay the claims they submit. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, the record indicates that the provider at issue was not enrolled with Medicare for the date of service at issue. There was no documentation to verify the provider's enrollment in Medicare for the date of service at issue. Therefore, we decided that the Plan does not have to pay for a standard wheelchair (K0001) and sales tax (S9999), provided on January 1, 2021, by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the addition of a tooth to an existing partial denture (D5650) provided on December 10, 2020 by an OON provider.
You asked the Plan to pay for the addition of a tooth to an existing partial denture. You say that you believed this bill would be paid in full because you purchased the dental rider. The Plan denied your request. The Plan says the total liability amount of $125.50 was applied correctly. The Plan also says that member liability is a contractual obligation under the Plan and cannot be waived.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a 50% coinsurance of the allowed amount, plus the difference between the billed amount and allowed amount because the services were received OON. Therefore, we decided that the Plan does not have to pay for the addition of a tooth to an existing partial denture (D5650) provided on December 10, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transportation (A0429) received February 21, 2021.You asked the Plan to waive the copayment forthe ambulance transportation. You say that the ambulance was called against your wishes.The Plan denied your request. The Plan says the correct cost share applied to the claim.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 $325 copayment for Ambulance Services. You have been asked to pay a $325 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amountbased 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 forthe ambulance transportation (A0429) received February 21, 2021
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for anesthesia services reported with CPT code 00811. We decided that the Plan does not have to pay for anesthesia services reported with CPT code 99100.
You asked the Plan to pay for anesthesia services reported with CPT codes 00811 and 99100. You say that you bill these codes often and have never had a problem before. The Plan says that these codes are Not Otherwise Classified (NOC) and require a description.
We decided that the Plan has to pay for anesthesia services reported with CPT code 00811.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed. When reporting an "unlisted procedure code" or a "not otherwise classified" (NOC) code, providers should include a narrative description. In this case, the CPT Code Manual definition of code 00811 is anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified. We looked at the file and Medicare rules. The billed code is not an unlisted or NOC code. The record does not support that a description of the service is required. Therefore, we decided that the Plan has to pay for anesthesia services reported with CPT code 00811.
We also decided that the Plan does not have to pay for anesthesia services reported with CPT code 99100.
The Plan follows Medicare rules. Medicare rules say that status code B indicates that payment for covered services is always bundled into payment for other services not specified. We looked at the files and Medicare rules. CPT code 99100 has a status code of B, meaning payment for this code is bundled into payment for other services. Therefore, we decided that the Plan does not have to pay for anesthesia services reported with CPT code 99100.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial nursing facility care (99306) provided January 21,
2021, by an out of network (OON) provider.
You asked the Plan to pay for initial nursing facility care. You say that you would like this claim reprocessed
for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for
these services rendered by an OON provider.
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 initial nursing facility care (99306) provided January 21, 2021, by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on November 28, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare
denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic
patients with suspected or documented cardiovascular disease.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.
This testing was ordered by an in-network provider. The file does not show that the plan provided notice that
genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved
by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on November 28, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 10, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you did not see the physician you only saw the physician assistant. You say that you paid a $5 copayment at the time of the visit and later received a bill for $35. The Plan denied your request. The Plan says the copayment 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 a $40 copayment for each specialist visit for Medicare-covered benefits.
You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show you were seen in a specialist's office. 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 provided on February 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency intubation (31500) and critical care (99292)
provided on July 16, 2020.
You asked the Plan to pay for an emergency intubation and critical care. You say that this was billed correctly.
The Plan denied your request. The Plan says these codes 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 31500 is intubation, endotracheal, emergency procedure.
The definition of 99292 is critical care, evaluation and management of the critically ill or critically injured
patient; each additional 30 minutes (list separately in addition to code for primary service).
We find that CPT codes 31500 and 99292 are not supported in the medical record. Specifically, the records do
not show that an emergency intubation was performed on the billed date of service, and there is not
documentation of the time spent on critical care. Based on this information, we decided that Medicare rules for
coverage of an emergency intubation and critical care have not been met. Therefore, we decided that the Plan
does not have to pay for an emergency intubation (31500) and critical care (99292) provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lens fitting services provided on September 10, 2020.
You asked the Plan to pay for contact lens fitting services. You say that this vision service should be covered. The Plan denied your request. The Plan says this is not a covered vision benefit. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract language.
The Plan is correct in this case. Medicare does not cover routine vision and eyewear services. The Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract does not list contact lens fittings as a covered benefit. Only the contact lenses or materials are covered with limitations. Therefore, we decided that the Plan does not have to pay for contact lens fitting services provided on September 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0482) provided on December 2, 2020.

You asked the Plan to pay for drug testing. You say that this should be covered as an in-network service. The Plan denied your request. The Plan says this was not billed with the correct POS.

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 testing at issue was billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0482) provided on December 2, 2020.