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

We decided that the Plan does not have to pay forCPT codes 95911 and 95886 provided on December 18, 2018.You asked the Plan to pay forCPT codes 95911 and 95886. You say that the medical records support the billing of CPT codes 95911 and 95886. The Plan denied your request. The Plan says the services are not covered.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 95911 is Nerve conduction studies; 9-10 studies. 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 CPT code 95911. Our reviewer says that the medical records do not support the billing of CPT code 95911. Our physician reviewer found CPT code 95911 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include documentation of Nerve conduction studies; 9-10 studies being performed on December 18, 2018, therefore this service cannot be verified. The documentation does indicate that a Nerve conduction study was performed, however, a different code should be selected to corroborate with the number of studies actually performed. Medicare rules also say that CPT code 95886 is a Type 1 add-on code and must be reported with a proper Primary Code. In this case, the primary code, 95911, has been denied for payment. CPT code 95886 is not eligible for payment as the primary code is not eligible for payment.We looked at this physician's review, the file, and Medicarerules. Based on this information, we decided that Medicare rules for coverage of CPT codes 95911 and 95886 have not been met.Therefore, we decided that the Plan does not have to pay forCPT codes 95911 and 95886 provided on December 18, 2018.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the charges forthe prostate-specific antigen (PSA) testing provided on December 10, 2019.You asked the Plan to waive the charges forthe PSA test. You say that you feel that this should be covered in full since you are supposed to get this covered once per year to check for prostate cancer.The Plan denied your request. The Plan says that this was billed as diagnostic and the Plan contacted the provider who confirmed it was meant to be diagnostic and not screening.The Plan must follow Medicare rules. Medicare rules say that screening PSA tests are covered by Medicare in the above listed situations. The Plan's contract says that enrollees are not charged cost sharing for this test.Although this may have been billed as a diagnostic test by the network laboratory, the Plan has failed to forwardsufficient information to support that this was correctly billed as diagnostic. There is no information provided on the billed diagnoses or even showing what CPT code was billed. This means that MAXIMUS cannot confirm that this was indeed billed as a diagnostic test and also we do not have any evidence to corroborate that you were not eligible for a PSA screening test on the date of service in question. As such, we find that Plan's denial rationale is not supported.Therefore, we decided that the Plan has to waive the charges forthe prostate-specific antigen (PSA) testing provided on December 10, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 20, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe office visit and cerumen removal. You say that you would like reconsideration because you were told no referral was needed for these services.The Plan denied your request. The Plan says the services rendered by an out-of-network provider were not authorized by the 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 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 forthe medical services provided on November 20, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveimplantation of hypoglossal nerve stimulatorYou asked the Plan to pre-approveimplantation of hypoglossal nerve stimulator. You say that you request the immediate review and approval of the procedure/treatment as recommended and requested by your physician.The Plan denied your request. The Plan says this service is not a Medicare covered benefit.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of implantation of hypoglossal nerve stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approveimplantation of hypoglossal nerve stimulator
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea dental crown on the left mandibular first premolar for the enrollee.You asked the Plan to pre-approvethe crown. You say that this is medically necessary.The Plan denied your request. The Plan says the tooth does not appear to have significant breakdown.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 the crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that the requested crown is not medically reasonable or necessary. Our physician reviewer found there were no clinical notes as to symptoms or testing of the tooth, and there is no clear x-ray view to indicate a deep recurrent decay.  Standard practice requires there be testing of the tooth by thermal insult and percussion testing at a minimum to determine the existence of an irreversible pulpitis or necrotic pulp that requires treatment. The record should indicate test results that allowed a determination of irreversible pulpitis, howeverthe records supplied do not support it at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met.Therefore, we decided that the Plan does not have to pre-approvea dental crown on the left mandibular first premolar for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea repeat upper endoscopy.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that an upper endoscopy is covered when specific criteria are met We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee reports having associated dysphagia for years. The upper endoscopy on January 28, 2020 showed a non-critical Schatzki ring that was not dilated. The follow up upper endoscopy on February 27, 2020 showed the Schatzki ring was dilated to a normal diameter of 16.5 millimeters. In the absence of dysphagia of other alarm symptoms or signs, the repeat upper endoscopy is not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea repeat upper endoscopy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe genetic testing provided on November 13, 2019.You asked the Plan to pay forthe testing. The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe genetic testing provided on November 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on November 15, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for the services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 services at issue in this appeal. 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 forthe medical services provided to the enrollee by an out-of-network provider on November 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe visual field exam and computerized ophthalmic imaging provided on December 31, 2019.You asked the Plan to waive the copayment forthese services. You say that you were told there would be no cost for these services.The Plan denied your request. The Plan says that you have a $35 copayment per visit for Medicare-covered specialty care services.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 $35 copayment for per visit for Medicare-covered specialty care services. You have been asked to pay a $35 copayment for these services. These services fall within the visit for Medicare-covered specialty care services 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 forthe visual field exam and computerized ophthalmic imaging provided on December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on November 13, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on November 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve elevating leg rests (K0195).
You asked the Plan to pre-approve elevating leg rests. You say that you are having surgery on your right foot which would be supported by pins and your foot would need to be elevated at all times. You will not be able to go to your post-op appointment. The Plan denied your request. The Plan says this request does not meet Medicare guidelines for coverage.
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 elevating leg rests. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that the member is currently using a wheelchair or has lower extremity edema. She was being fitted with a mid-calf boot which would not cross the knee. Providing an elevated leg rest is not 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 elevating leg rests have not been met. Therefore, we decided that the Plan does not have to pre-approve elevating leg rests (K0195).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional acupuncture visits.
You asked the Plan to pre-approve additional acupuncture visits. You say that these treatments helped with your knee pain. The Plan denied your request. The Plan says you have exhausted your supplemental acupuncture benefit.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90 period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. The Plan covers 12 in-network acupuncture treatments per year in addition to what Medicare covers. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the record does not show that you have CLBP. The record does show that you have had 12 acupuncture visits under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve additional acupuncture visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 3, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on June 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extractions (D7210 x 3), the removal of tooth roots (D7250 x 4), the alveoloplasty not in conjunction with extractions (D7321 x 2), and the medication (D9612) provided on November 20, 2019.
You asked the Plan to pay for 3 additional extractions, 4 additional procedures for removal of tooth roots, the 2 alveoloplasty, and the medication. You say that the services should be covered since they were needed as a result of an accident. The Plan denied your request. The Plan says the services you received are dental in nature. The Plan says the frequency limits for the extractions and the removal of tooth roots have been exceeded. The Plan says alveoloplasty not in conjunction with an extraction is not a covered service. The Plan also says the medication is not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and extractions and removal of tooth roots are listed as covered services, the frequency limits of 2 per calendar year have been exceeded. The record shows that the Plan paid for 2 extractions and 2 removal of tooth roots that you received on November 20, 2019. Additionally, the alveoloplasties and medication are not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the surgical extractions (D7210 x 3), the removal of tooth roots (D7250 x 4), the alveoloplasty not in conjunction with extractions (D7321 x 2), and the medication (D9612) provided on November 20, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 3, 2019 to September 26, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment is not allowed for this service because it was billed with an incorrect type of bill 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, this claim has been submitted with an invalid type of bill code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 3, 2019 to September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided on October 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for acupuncture services. You say that you cannot afford this bill. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers were found.
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 acupuncture services provided on October 29, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient lab work provided by participating providers on January 9, 2020.
You asked the Plan to waive the copayment for outpatient lab work. You say that you were told this visit was free. The Plan denied your request. The Plan says the correct copayments have 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). Your contract with the Plan clearly says that you must pay a $20 copayment for outpatient diagnostic tests/in-network/labs. You have been asked to pay a $29.71 ($20+ $9.71 = $29.71) copayment for outpatient lab work. There is a $20 copayment per provider for lab work. The lab tests provided went beyond an annual wellness exam; therefore, the correct copayments have been applied. Outpatient lab work falls within the outpatient diagnostic tests/in-network/labs 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 outpatient lab work provided by participating providers on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 27, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on November 27, 2019.