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

We decided that the Plan does not have to pay for sedation services (99152) provided on June 8, 2020.

You asked the Plan to pay for sedation services. You say that this was billed correctly. The Plan denied your request. The Plan says this code is 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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. 

We find that CPT code 99152 is not supported in the medical record. Specifically, the submitted medical records do not document the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation services (99152) provided on June 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay intraoral periapical dental X-rays (D0220) received on June 4, 2020, and for an unspecified preventive dental procedure (D1999) performed on May 13 and June 4, 2020.

You asked the Plan to pay intraoral periapical dental X-rays and for an unspecified preventive dental procedure. You say that a representative of the Plan told you that you were fully covered for these services. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan does not have to pay for intraoral periapical dental X-rays received on June 4, 2020.

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. The Plan covers intraoral periapical dental X-rays once per calendar year. 

We looked at the file and the Plan contract. We noted that the X-rays received on June 4, 2020, are the second instance of the service within the calendar year. Based on this information, we decided that the Plan's rules for coverage of intraoral periapical dental X-rays have not been met. Therefore, we decided that the Plan does not have to pay intraoral periapical dental X-rays (D0220) received on June 4, 2020.

The Plan does not have to pay an unspecified preventive dental procedure performed on May 13 and June 4, 2020.

Your dental provider did not specify the procedure performed on May 13 and June 4, 2020. Though the Plan offers a dental benefit in excess of Medicare coverage, we are unable to verify that the requested items or services are among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an unspecified preventive dental procedure (D1999) performed on May 13 and June 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric treatment.

You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage
criteria has not been met.

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 inpatient psychiatric treatment. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found based upon review of the records provided, this enrollee does not meet the
criteria for treatment in an acute inpatient mental health treatment beyond the date in question of November 19,
2020 forward and could have been treated in a lesser restrictive setting. The enrollee was not showing any
suicidal or homicidal ideation, auditory or visual hallucinations, or delusions and was not showing any
behaviors or aggression. The enrollee was being cooperative and compliant while not showing any acute
threats to safety. The enrollee was waiting on placement.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an IRF admission provided from November 21, 2019, through November 24, 2019.

You asked the Plan to pay for the IRF admission. The Plan denied your request. The Plan says that generally, the enrollee must receive care from a network provider. In most cases, care received from a non-network provider will not be covered.

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 IRF admission. 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 an IRF admission provided from November 21, 2019, through November 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 30, 2020, and April
17, 2020, by an OON provider.

You asked the Plan to pay for practitioner visits. You say that authorization should not be needed for
telemedicine. 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 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 the medical services provided on March 30, 2020,
and April 17, 2020, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy
services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient
basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and apicoectomy
provided on May 18, 2020.

You asked the Plan to pay for the problem focused limited oral evaluation and apicoectomy. You say that you
were never informed that the treating provider was not in-network. The Plan denied your request. The Plan says
the treating provider opted out of Medicare effective January 1, 2016, to January 4, 2022. The Plan also says
that no contacts were made to the Health Plan in regard to your cost share or provider questions for the
services.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the
problem focused limited oral evaluation and apicoectomy provided on May 18, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health occupational therapy (OT), speech therapy (ST), and home health aide visits (HHA).

You asked the Plan to pre-approve the home health services. You say that these services are medically necessary and should be allowed as they will improve the enrollee's health. The Plan denied your request. The Plan says the documentation does not show that OT is medically necessary to improve or maintain the enrollee's condition, nor are speech therapy or HHA services required.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 home health services. Our reviewer says that the documentation does not support that the requested home health care is reasonable and necessary. Our physician reviewer found the enrollee is not shown to have skilled therapy needs (OT, ST).

The enrollee appears unable to fully participate in skilled therapy. The enrollee does not appear to have shown signs of improvement from prior skilled therapy. The enrollee's care needs appear to be custodial and can be provided at a lower level of care. According to the health plan's records, the enrollee was approved for some HH RN visits. If so, the enrollee may qualify for some associated HHA services. However, records regarding what nursing services are being provided and how HHA services might corresponded with the RN services has not been provided. Therefore, this review has not shown the HHA services to be medically necessary and reasonable. 

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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health occupational therapy (OT), speech therapy (ST), and home health aide visits (HHA).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 26, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed,
however, the physician must clearly document, in the medical record, his or her intent that the test be
performed.

We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided
that the Plan does not have to pay for the laboratory services provided on April 26, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pre-approvecomputed tomography (CT) scans of the chest, abdomen and pelvis.You asked the Plan to pre-approvethe requested imaging. You say that this imaging is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.Our Medical director looked at the case file and the reopen request. Our Medical Director says that the Plan is correct in this case. The most recent medical record in the case file is dated February 24, 2020. The review of systems at that time did not identify any chest, abdominal, or pelvic complaints. At that time, the enrollee's BMI was normal, and his physical exam was unremarkable. The available documentation is insufficient to support that the requested CT scans of the chest, abdomen and pelvis were medically reasonable and necessary for the enrollee in this case at the time of the determination.Medicare coverage criteria were 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 the requested imaging have not been met.Therefore, we decided that the Plan does not have to pre-approvecomputed tomography (CT) scans of the chest, abdomen and pelvisfor the enrollee
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the chest for the enrollee.You asked the Plan to pre-approvethis service. You say that the requested CT scan is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.Our Medical Director reviewed the case file and the reopen request. At issue is coverage for a CT scan of the chest. The Maximus Physician Reviewer determined that an EGD showed a gastric mass, and that based on this, a CT scan is medically reasonable and necessary. The Plan requested a reopen stating at the time of the request, there was no disease of the chest documented, nor were there signs or symptoms of chest disease.The Plan is correct. The reviewer incorrectly stated that a CT of the abdomen was denied, and that the CT was medically reasonable and necessary based on the EGD findings. The documentation does not support that a CT scan of the chest was medically reasonable and necessary for the enrollee in this case.  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 service have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the chest for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services provided to you on October 16, 2019.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that these services
are not payable.

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.

You were provided the lab services by a contract provider. The file does not show that the Plan provided notice
that the lab services would not be covered. Under Medicare rules, this means the lab services is considered
approved by the Plan. You were provided the lab services with the reasonable expectation that the services
would be covered. Therefore, we decided that the Plan has to pay for the lab services provided to you on
October 16, 2019.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and two additional intraoral periapical x-rays (D0230 x2) provided on July 15, 2020.

You asked the Plan to pay for the intraoral periapical x-rays. You say that you can only have this kind of x-ray because you have an upper plate, and only 9 bottom teeth. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.

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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and two additional intraoral periapical x-rays (D0230 x2) provided on July 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and attachments for the enrollee.

You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that the member does not have a qualifying diagnosis for a group 3 power wheelchair.

The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:

1. A neurological condition;

2. Myopathy; or

3. Congenital skeletal deformity.

The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair and attachments for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out-ofnetwork
provider.

You asked the Plan to pre-approve the medical services. You say that the member feels comfortable with the
requested oncologist due to the seriousness of the member's breast cancer. The Plan denied your request. The
Plan says this provider is an out-of-network provider and the service is available within the 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 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
the medical services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit (E0745)
provided June 22, 2020.

You asked the Plan to pay for neuromuscular stimulator. You say that you are sending claim for
reconsideration. According to Medicare guidelines this is a covered service for the diagnosis of muscle wasting
and atrophy. The Plan denied your request. The Plan says there is no actual physical exam. All information was
provided over the phone. There are no clinical notes from the enrollee's primary health provider and no
documented attempts to contact the enrollee's local physician and the enrollee is not in an eligible geographical
area for telehealth services.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.

A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for neuromuscular stimulator,
electronic shock unit (E0745) provided June 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic digital breast tomosynthesis services coded
77061 provided on April 20, 2020.

You asked the Plan to pay for the diagnostic digital breast tomosynthesis services. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not
payable.

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 77061 is diagnostic digital breast tomosynthesis;
unilateral.

We find that CPT code 77061 is not supported in the medical record. Specifically, this code has a status code of
"I' A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for
reporting of, and payment of these services. Based on this information, we decided that Medicare rules for
coverage of the diagnostic digital breast tomosynthesis services have not been met. Therefore, we decided that
the Plan does not have to pay for the diagnostic digital breast tomosynthesis services coded 77061 provided on
April 20, 2020.