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

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating facility on November 29, 2019 to November 30, 2019You asked the Plan to waive the copayment for a CT scan. You say that you would like this claim revisited. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment for outpatient diagnostic tests/advanced imaging service. The enrollee has been asked to pay a $225 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests/advanced imaging service benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan provided by a participating facility on November 29, 2019 to November 30, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fora hallux valgus correction (28295) provided on October 3, 2019.You asked the Plan to pay fora hallux valgus correction. You say that this should be covered.The Plan denied your request. The Plan says this code is not supported in the records.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 28295 is correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal metatarsal osteotomy, any method.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 a hallux valgus correction. Our reviewer says that the billing of this code is not supported. Our physician reviewer found the submitted medical records do not contain documentation that sesamoidectomy was completed, therefore, this code cannot be verified.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a hallux valgus correction have not been met.Therefore, we decided that the Plan does not have to pay fora hallux valgus correction (28295) provided on October 3, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on March 1, 2019 by an out of network (OON) provider.You asked the Plan to pay for the office visit. You say that you have been receiving services at this facility all along and do not understand why it is not being covered now.The Plan denied your request. The Plan says prior authorization was not requested or received for the services, therefore coverage criteria has 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 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 for an office visit (99214) provided on March 1, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection, expandable controller, and harness for the enrollee.You asked the Plan to pre-approve the accessories. You say that this is medically necessary.The Plan denied your request. The Plan says this is not medically necessary.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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not indicate that the enrollee requires a proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head control, etc.) other than a standard proportional joystick, a non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the joystick. The enrollee does not need an expandable controller to be able to operate one or more of the following: a separate display (i.e., for alternate control devices); other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control) or an attendant control. The documentation indicates the enrollee has sufficient strength and function to control the power features through their own individual (already included) switches.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 accessories have not been met.Therefore, we decided that the Plan does not have to pre-approve an electronic connection, expandable controller, and harness for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the right hand (73220).You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the member's symptoms have returned.The Plan denied your request. The Plan says one advanced imaging study has already been performed and now a second is requested without a lab work up.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 the MRI. Our reviewer says that this request for MRI will be considered not medically necessary, based on the records provided. Our physician reviewer found repeat MRI would not lead to any change in the diagnosis or improved treatment in this setting, especially only a few months after the initial MRI of the right hand.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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approve an MRI of the right hand (73220).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99335) rendered by the out of network (OON) provider on December 7, 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 was provided by an out of network provider at a non-participating facility, without prior authorization.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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service.Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99335) rendered by the out of network (OON) provider on December 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for medical services provided January 1, 2019 to March 25, 2020.
You asked the Plan to waive the copayments for the medical services. You say that the cost-sharing should be waived for the services rendered. The Plan denied your request. The Plan says at the time the services were provided, the enrollee out-of-pocket maximums for each year had not been met.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The plan contracts for the years at issue fully disclose the maximum out-of-pocket costs for the enrollee. The record shows that at the time the services were provider in 2019, and in 2020, the out-of-pocket maximums were not met yet for either year. Therefore, we decided that the Plan does not have to waive the copayments for medical services provided January 1, 2019 to March 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flexitouc hpneumatic compressor (E0652) and accessories (E0667).You asked the Plan to pre-approve a Flexitouch pneumatic compressor and accessories. You say that this is medically necessary because a basic PCD causes the enrollee pain.The Plan denied your request. The Plan says the criteria for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that PCD coded as E0652 used to treat lymphedema not extending onto the chest, trunk and/or abdomen or CVI will be denied as not reasonable and necessary. PCD related accessories are covered only when the appropriate, related base PCD is covered.We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee's lymphedema extends onto the chest, trunk, or abdomen. Based on this information, we decided that Medicare rules for coverage of a Flexitouch pneumatic compressor and accessories have not been met.Therefore, we decided that the Plan does not have to pre-approve a Flexitouch pneumatic compressor (E0652) and accessories (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on November 27, 2019.You asked the Plan to waive the copayment for specialist services. You say that you feel that you should only be responsible for the surgery copayment.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 a $50 copayment for services obtained by a specialist. You have been asked to pay a $50 copayment for specialist services. Specialist services fall within the physician/practitioner services, including doctor's office visits 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 specialist services provided on November 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nasal/sinus endoscopy with dilation for the enrollee.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says the CT scan of the sinuses demonstrates no evidence of sinusitis or obstruction.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the guidelines for balloon sinuplasty state that there should be abnormal CT findings that support the diagnosis of chronic sinusitis or recurrent acute sinusitis. The enrollee's CT scan did not show these findings. Therefore, a procedure to dilate the sinuses like the balloon sinuplastyis not medically reasonable nor 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 services have not been met.Therefore, we decided that the Plan does not have to pre-approve a nasal/sinus endoscopy with dilation for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 15, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 physician's services provided on November 15, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychotherapy visit, 30 minutes (90832) provided on June 14, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe psychotherapy visit, 30 minutes provided by an OON provider.You say that the services were provided and payment should be rendered.The Plan denied your request. The Plan says prior authorization was not requested or received and the services were not emergent in nature. Therefore, coverage criteria has 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 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 fora psychotherapy visit, 30 minutes (90832) provided on June 14, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on January 23, 2020.You asked the Plan to waive the copayment for the MRI. You say that the MRI was needed in order to make medical decisions. 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 a $225 copayment for in-network diagnostic radiology other than CT scan performed by a provider other than your primary care physician.  You have been asked to pay a $221.57, which is less than the standard copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 MRI provided on January 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pioglitazone HCL 45mg Tablets.You asked the Plan to pre-approve Pioglitazone. You say that Pioglitazone is medically necessary.The Plan denied your request. The Plan says this type of drug is not eligible for coverage under the Part B medical benefit.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 pre-approve Pioglitazone HCL 45mg Tablets.Benefits for Pioglitazone 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on November 27, 2019 and November 29, 2019.You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says that 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 and the referring provider are not network providers 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 physical therapy services provided on November 27, 2019 and November 29, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve admission to an inpatient mental health facility for the enrollee.You asked the Plan to pre-approve the admission. The plan did not provide the appeal reason.The Plan denied your request. The plan did not provide the denial reason.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan sent a corrupted case file, so MAXIMUS does not have access to the majority of the case information. The plan has not resent the case file as of this case's due date.Therefore, we decided that the Plan has to pre-approve admission to an inpatient mental health facility for the enrollee.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on November 15, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the plan should pay this claim.
The Plan denied your request. The Plan says there is no itemized shipping/billing invoice or evidence of an
established relationship between the member and ordering physician.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the physician order and proof of delivery
documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the
supplies provided in this case. Neither proof of delivery nor the invoice was submitted. Therefore, we decided
that the Plan does not have to pay for the lumbar-sacral orthosis provided on November 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 81001) provided to September 30, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 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 81001 is "Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy".We asked our coding 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 services. Our reviewer says that the use of CPT code 81001 is not supported by the records provided. Our coding reviewer found that the medical records do not include a lab report with results from a "Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy", therefore this service cannot be verified. The medical records indicate "Nosuitable specimen was received for the test requested."We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for the services (CPT 81001) provided to September 30, 2019.