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

We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on October 19, 2020.

You asked the Plan to pay for the ambulance service and ground mileage. You say that the enrollee's diagnosis is not related to hospice, and the trip is not related to hospice care. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance service and ground mileage provided on October 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 21, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the requested testing is not reasonable or necessary, and authorization is not recommended at this time.

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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the reviewed documentation indicates that the patient was newly diagnosed with a high-grade Glioblastoma. It appears that she underwent CDx testing. The appeal letter stated that her provider requested testing. There are no submitted medical records from the provider to show that there was a decision to seek further treatment and why testing was requested. The CDx testing does not meet Medicare guidelines for this reason and would not be 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray provided to the enrollee on October 7, 2020 and billed under Claim A.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan stated that Claim A denied because the Plan had already paid for this service under another claim. The Plan states the NPI website shows that both providers are listed as Radiology and Nuclear Specialists and both providers work within the same professional practice or group. The Plan states the correct billing of this service needed to include modifier -59 to establish a separate and distinct service was provided. 

The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met.

Therefore, we decided that the Plan does not have to pay a chest x-ray provided to the enrollee on October 7, 2020 and billed under Claim A.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head provided to the enrollee on September 22, 2020 and billed under Claim A.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan stated that Claim A denied because the plan had already paid for this service under another claim. The Plan states the NPI website shows that both providers are listed as Diagnostic Radiology Specialists and both providers work within the same professional practice or group. The Plan states the correct billing of this service needed to include modifier -59 to establish a separate and distinct service was provided. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met.
Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan of the head
provided to the enrollee on September 22, 2020 and billed under Claim A.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the nursing home visits rendered on January 22, 2021 and January 29, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that procedure code 99308 is bundled to the primary procedure code.

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 states that procedure code 99308 (nursing home visit) is not separately payable as it is a column II code when billed with the approved codes. The file shows that the Plan approved codes 11043 and 10042 (debridement); however, code 99308 is not a column II code when billed with 11043 or 11042 as a column I code. The Plan has provided no documentation or Medicare rules to support that code 99308 is not separately payable. Therefore, we decided that the Plan has to pay for the nursing home visits rendered on January 22, 2021 and January 29, 2021.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-Plan referral for lipedema surgery.

You asked the Plan to pre-approve an out-of-Plan referral. You say that the requested out-of-network referral for the lipedema liposuction procedure with a specialist who specializes in liposuction for lipedema is medically necessary. You say that you do not think the Plan has in-network providers who understand how much lipedema is misdiagnosed and does not feel they can perform liposuction for the lipedema. The Plan denied your request. The Plan says that they have in-network plastic surgeons who specialize in the treatment of your condition and who can provide liposuction as an option.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.

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 an out-of-Plan referral. Our reviewer says that the requested out-of-Plan referral is not medically necessary. Our physician reviewer found the enrollee is with a diagnosis of lipedema. A 4-stage lipedema surgical procedure has been proposed. The documentation supports that the Plan's referral recommendations are appropriate for the evaluation and potential treatment of the enrollee's condition. The clinical documentation is insufficient to demonstrate that evaluation and treatment by the requested out-of-network provider is medically necessary for the enrollee in this case. The Plan has shown that they have in-network providers who meet the Standards of Care required for treatment of the enrollee's condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an out-of-Plan referral have not been met. Therefore, we decided that the Plan does not have to pre-approve an out-of-Plan referral for lipedema surgery.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan rendered on March 20, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the duplex scan rendered on March 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81230, 81225, 81227, 81226) provided from April 8, 2020, to April 9, 2020, by an out of network (OON) provider.

You asked the Plan to pay for laboratory services. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were not authorized.

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 laboratory services (81230, 81225, 81227, 81226) provided from April 8, 2020, to April 9, 2020, by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 12, 2020.

You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics.
The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.

The ambulance company did not provide transport services on July 12, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 12, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of heart (CPT code 93306) provided on November 12, 2020.

You asked the Plan to waive the copayment for the ultrasound. You say that you would an explanation why this claim was processed differently compared to the previous three (3) claims. The Plan denied your request. The Plan says the previous claims for the same service all provided at this facility were not processed correctly. The Plan states they opted to not reprocess those claims to assess you the $200 co-pay.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the ultrasound of heart (CPT code 93306) on November 12, 2020. You were asked to pay a $200 copayment for the diagnostic test. Your 2020 EOC states that enrollees must pay a $200 copayment per visit for any diagnostic test or special procedure that is provided in an outpatient or ambulatory surgery center or in a hospital operating room, or if it is provided in any setting and a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or to minimize discomfort. 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 ultrasound of heart (CPT code 93306) provided on November 12, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that the member needs wound care before she can be
sent to boarding care or home. The Plan denied your request. The Plan says that that the continuation of skilled
services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or at the
home with home health care services.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 services. Our reviewer says that
SNF services are medically reasonable and necessary for the enrollee. The treatment of extensive decubitus
ulcers and widespread skin disorders qualifies as a required skilled nursing service. The documentation
supports that the enrollee requires skilled therapy services. The documentation supports that the enrollee in this
case is reasonably expected to benefit from skilled nursing and therapy services on a daily basis on an inpatient
basis in a skilled nursing facility. Our physician reviewer found that the enrollee's condition meets Medicare
criteria for SNF services.

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 services have been met. The Plan must continue coverage for the SNF
skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or
the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled
nursing facility (SNF) services 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that there are Acute Rehabilitation facilities within your health plan.
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 acute inpatient rehabilitation facility (IRF) admission and services 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 an adjunctive pre-diagnostic test (D0431) and gingival irrigation (D4921) provided on January 14, 2021.
You asked the Plan to pay for the dental services. You say that these services were necessary after you had to miss a few check-ups due to the pandemic. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental benefit.
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 an adjunctive pre-diagnostic test (D0431) and gingival irrigation (D4921) provided on January 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for teeth cleaning (D1110), and bitewing radiographic images (D0274) provided on December 9, 2019.

You asked the Plan to pay for teeth cleaning, and bitewing radiographic images. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says records indicate you were not enrolled in the Dental Rider at the time the services were rendered, and therefore, the services at issue are not covered.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for teeth cleaning (D1110), and bitewing radiographic images (D0274) provided on December 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the medical record does not indicate that the enrollee requires services that they are
not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules
are not satisfied. The requested service cannot be recommended.

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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI scan of the pelvis (72197) provided on December 14, 2020.

You asked the Plan to waive the copayment for an MRI of the pelvis. You say that you should not have to pay the copayment when the Plan's share is lower. The Plan denied your request. The Plan says the correct copayment was 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). Your contract with the Plan clearly says that you must pay a $100 copayment for a Medicare-covered MRI at a freestanding provider. 

You have been asked to pay a $100 copayment for an MRI of the pelvis. An MRI of the pelvis 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 an MRI scan of the pelvis (72197) provided on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate upper denture (D5130) provided on October 28, 2020 by the out of network provider.
You asked the Plan to pay for the dental service. You say that you are being balance billed for the amount of $1,149 over your annual dental benefit of $3,500. You say that you received an authorization saying that these services were approved. You say that you were not made aware that you exceeded your maximum benefit until you received a bill. The Plan denied your request. The Plan says there is an annual maximum benefit of $3,500 for covered dental services. The Plan says that the annual maximum has been exhausted. The Plan says that the authorization states the approval does not guarantee that the plan will pay for the services as payment of covered services may depend on other plan rules. The Plan also says that at the time the authorization was received, you had not exhausted your benefit.
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 and the immediate denture is listed as covered, the annual maximum benefit has been exhausted.
The Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay for the immediate upper denture (D5130) provided on October 28, 2020 by the out of network provider.