Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric services provided on March 11, 2019.
You asked the Plan to pay for the psychiatric services. 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 services was not filed until August 27, 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 services provided on March 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on September 30, 2020.
You asked the Plan to pay for nurse practitioner services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 nurse practitioner services provided on September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on February 20, 2020. You asked the Plan to waive the copayment for the specialist office visit. You say that it was your understanding that the claim was being waived through the end of 2020. You say this was a telehealth visit with the doctor. 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 $45 copayment for provider and professional services at an in-network specialist's office. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls 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 the specialist office visit provided on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 12, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
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
physician's services. 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 August 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug provided on October 28, 2020.
You asked the Plan to waive the coinsurance for the Part B drug. You say that you did not get an injection. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay $1.06 which is 20% of the allowed amount for the Part B drug. The allowed amount is $5.32. ($5.32 x 20% = $1.06). The Part B drug falls within the "Medicare Part B prescription drugs" benefit category. The medical record shows you received an injection of 1cc Kenalog to the right middle finger under aseptic conditions. Kenalog is considered a Part B prescription drug.
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 Part B drug provided on October 28, 2020.
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 benefit from the rehab. The Plan denied
your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower
level of care.
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. You
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a
lower level of care. Our physician reviewer found that your 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on October 27, 2020.
You asked the Plan to pay for the nurse practitioner 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 nurse practitioner services provided on October 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient mental health hospital stay
provided from January 21, 2020, to January 24, 2020.
You asked the Plan to waive the copayment for the inpatient mental health hospital stay. You say that you did
not have a choice where you were being sent (in-network versus out-of-network). 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 $300
copayment per day for days 1-5, then a $0 copayment after day 5.
You have been asked to pay a $300 copayment per day for the inpatient mental health hospital stay. ($300 x 3
inpatient days = $900). The inpatient mental health hospital stay falls within the "Inpatient mental health care"
benefit category. The record shows this hospital is an in-network facility.
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 an inpatient mental health hospital stay provided from
January 21, 2020, to January 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the eye injection or the Part B drug provided on October 9, 2020. You asked the Plan to waive the cost share for the eye injection and the Part B drug. You say that you have been getting this exact same procedure done every few months and have not been charged a large copayment. 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 $500 copayment for each outpatient hospital service and observation service and 20% coinsurance each Medicare-covered Part B drug. You have been asked to pay a total of $306.40 for the eye injection and the Part B drug. The eye injection falls within the "Outpatient hospital services" benefit category. The Part B drug 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 cost share for the eye injection or the Part B drug provided on October 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Visco-3 injections. You asked the Plan to pre-approve Visco-3 injections. You say that you are in pain and need this medication to alleviate pain. The Plan denied your request. The Plan says that the denial of Visco-3 was appropriate given the clinical scenario and the guidance presented above. The Plan must follow Medicare rules. Medicare rules say that viscosupplementation of joints other than the knee(s) will be considered not reasonable and necessary and will not be subject to coverage. We looked at the file and Medicare rules. The file indicates that Visco-3 is being requested for the treatment of hip osteoarthritis. Based on this information, we decided that Medicare rules for coverage of Visco-3 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Visco-3 injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe bone marrow aspiration for bone grafting (20939).You asked the Plan to pre-approvethe bone marrow aspiration for bone grafting. You say that this service is medically necessary for the enrollee's condition.The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery has not been demonstrated.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 bone marrow aspiration for bone grafting. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental in cases of spinal fusion. More research is needed to show safety and efficacy. Iliac crest bone graft is the gold standard for bone graft.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 bone marrow aspiration for bone grafting have not been met.Therefore, we decided that the Plan does not have to pre-approvethe bone marrow aspiration for bone grafting (20939).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay fora positron emission tomography (PET) scan provided to the enrollee on March 18, 2020 and billed under code 78815-26-PI.You asked the Plan to pay this claim. You say that these services should be paid by the Plan.The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial stating the service was medically necessary. The Plan requested a reopen and stated that the issue was not medical necessity but that the claim was notbilled with an appropriate diagnosis code. The Plan states this service wasbilledwithdiagnosis code R59.9 (Enlarged lymph nodes,unspecified).  The  Medicare  Claims  Processing  Manual,  Chapter  13,  Section  60.1,  it  states  "Claims for PET scan services must be billed using the ASC X12 837 professional claim format or on Form-CMS 1500 with the appropriate HCPCS or CPT code and diagnosis codes to the A/B MAC (B)." The Plan states National Coverage Determination (NCD) for Positron Emission Tomography (FDG) for Oncologic Conditions (220.6.17), shows that diagnosis code R59.9 is not listed as an appropriate diagnosis code. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate diagnosis codes. In this case the diagnosis code submitted on the claim for payment is not a covered code on the NCD for this type of PET scan. The argument was not medical necessity but the fact the claim could not be paid as billed due to the omission of an acceptable diagnosis code. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay fora positron emission tomography (PET) scan provided to the enrollee on March 18, 2020 and billed under code 78815-26-PI.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on September 3, 2020.You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says authorization is required for non-contracted providers.Medicare rules say that plans can require enrollees to getcare 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 diagnostic radiology services. 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 diagnostic radiology services provided on September 3, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveVumerity cap 231mg for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee does not have a Medicare Part D benefit or a separate pharmacy 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 Plandoes not haveto pre-approveVumerity cap 231mg for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on May 12, 2020.You asked the Plan to pay for the drug test. 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 drug test. 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 a drug test provided on May 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora targeted genomic sequence analysis panel (81450) provided on August 12, 2020.You asked the Plan to pay fora targeted genomic sequence analysis panel. You say that this is documented in the records.The Plan denied your request. The Plan says this code is not supported.The Plan mustfollow 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 81450 is targeted genomic sequence analysis panel,hematolymphoid neoplasm or disorder, DNA analysis, and RNA analysis when performed, 5-50 genes (eg, BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KRAS, KIT, MLL, NRAS, NPM1, NOTCH1), interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed.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 targeted genomic sequence analysis panel. Our reviewer says that this code is not supported. Our physician reviewer found the submitted documentation does not include a physician order to verify the physicians request of the services to be performed.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 targeted genomic sequence analysis panel have not been met.Therefore, we decided that the Plan does not have to pay fora targeted genomic sequence analysis panel (81450) provided on August 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea motorized wheelchair for the enrollee.You asked the Planto pre-approvethe wheelchair. You say that this is medically necessary.The Plandenied your request. The Plansaysalternatives to this wheelchair include physical therapy, pain management, use of a walker and includes the use of a manual wheelchair.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the documentation does not indicate the enrollee's personal mobility deficit impairs participation in MRADLs in the home. It isnot clear why the mobility deficit cannot be helped effectively by a walker or manual wheelchair in the home. The documentation does not reveal a detailed home assessment indicating that the enrollee can safely maneuver the wheelchair in the home. The documentation does not reveal that the enrollee requires an arm height that is different from the standard or that the enrollee will spend at least 2 hours per day in the chair.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 wheelchair have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea motorized wheelchair for the enrollee
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from February 1, 2020, to February 5, 2020.You asked the Plan to pay forhome health services. You say that this was billed correctly.The Plan denied your request. The Plan says this was not billed with a correct HIPPS code.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the billed HIPPS code is not in the correct format.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from February 1, 2020, to February 5, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to you from May 19, 2020, to August 4, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this type of provider is not payable for the services.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules.You were provided the services by a licensed marriage family therapist. This type of provider is not eligible to enroll inthe Medicare Program. Providers who are not enrolled in the Medicare Program cannot receive payment for services provided to a Medicare beneficiary.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 forthe services provided to you from May 19, 2020, to August 4, 2020.