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

We decided that the Plan does not have to pay forTAP block (64488) provided on February 4, 2020.You asked the Plan to pay forthe TAP block. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the service billed.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 64488 is transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed).We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying therequest to pay for the TAP block. Our reviewer says that CPT code 64488 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report supports a Pectoralis Block, and does not support TAP Block.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the TAP block have not been met.Therefore, we decided that the Plan does not have to pay forTAP block (64488) provided on February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on September 4, 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 September 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora surgical sacroiliac (SI) joint injection provided on March 11, 2020.You asked the Plan to waive the copayment foroutpatient surgery. You say that you were in an office and not a hospital room, and the costs involved were not explained to you.The Plan denied your request. The Plan saysthe copayment amount you are being charged is correct.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 saysthat you must pay $295 copayment for outpatient surgery at an outpatient hospital. The procedure you received is considered to be an outpatient surgical service, and the rendering provider was an outpatient hospital facility.You have been asked to pay $295 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 fora surgical sacroiliac (SI) joint injection provided on March 11, 2020.Your complaint regarding not being told about the cost-share for this service is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on December 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 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 lab tests provided on December 11, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided on April 20, 2020 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring facility is also out-of-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 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 Planhas 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 forskilled nursing services provided on April 20, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that you have knee pain. The Plan denied your request.
The Plan says that this is not covered when purchased from the pharmacy.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Euflexxa.
Benefits for Euflexxa may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on December 2, 2019.You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory requisition.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, laboratory requisition, or medical records to support the code billed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met.Therefore, we decided that the Plan does not have to pay for drug testing provided on December 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment.
You asked the Plan to pre-approve inpatient mental health 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 mental health treatment. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found based upon review of the records provided, you do not meet the criteria for
continued acute inpatient mental health treatment for the dates in question of July 23, 2020 forward as you
were not shown to be a danger to yourself or others. You were not showing any auditory or visual
hallucinations and were cooperative/compliant with treatment. You were not showing any withdrawal
symptoms.
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 mental health treatment have not been met. Therefore, we decided that
the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vertebral augmentation/kyphoplasty and anesthesia (22514 and 01922).You asked the Plan to pre-approve vertebral augmentation/kyphoplasty and anesthesia. You say that you would like reconsideration because you are in severe pain and are unable to move. The Plan denied your request. The Plan says this service is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve vertebral augmentation/kyphoplasty and anesthesia. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you fail to meet LCD criteria due to non-recommendation by the neurologist and failure of the MRI todemonstrate any progression of vertebral body height loss, > 25% vertebral body height reduction, or kyphotic deformity. In addition, there is no indication that your pain is progressing.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of vertebral augmentation/kyphoplasty and anesthesia have not been met. Therefore, we decided that the Plan does not have to pre-approve vertebral augmentation/kyphoplasty and anesthesia (22514 and 01922).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone Cap 5mg.
You asked the Plan to pre-approve Oxycodone Cap 5mg. You say that the requested medication is necessary.
The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a
separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for
coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycodone Cap 5mg.
Benefits for Oxycodone Cap 5mg may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RFA of the lateral sacral branches.
You asked the Plan to pre-approve RFA of the lateral sacral branches.. You say that you would like reconsideration because this is a Medicare covered benefit. The Plan denied your request. The Plan says medical research articles have not shown that the use of this kind of treatment improves the outcomes.
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 RFA of the lateral sacral branches. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/ investigational and is the subject of the ongoing clinical trials. The member is not enrolled in a clinical trial. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFA of the lateral sacral branches. have not been met. Therefore, we decided that the Plan does not have to pre-approve RFA of the lateral sacral branches.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean electrical nerve stimulator (63650).You asked the Plan to pre-approvethe electrical nerve stimulator. You say that you would like reconsideration because this service is medically necessary.The Plan denied your request. The Plan says the member's current medication regimen is effective in treating their symptoms.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 electrical nerve stimulator. 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 documentation of a trial stimulator attempt. Also, there is no clear documentation of a failure of current pain medication.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof the electrical nerve stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approvean electrical nerve stimulator (63650).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on June 8, 2019.You asked the Plan to pay for the drug testing. 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 supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the documentation does not support any evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on June 8, 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 January 9, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 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 January 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea spinal cord stimulator implantation.You asked the Plan to pre-approvea spinal cord stimulator implantation. You say that the enrollee needs a spinal cord stimulator for chronic back painand the medical records have been faxed several times.The Plan denied your request. The Plan says the medical records to support the criteria were not complete.The Plan must follow Medicare rules. The rules say that a spinal cord stimulator trial can be covered only for patients who have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. Such screening must include a psychological evaluation. The file does not show that a psychological evaluation has been conducted in conjunction with this request for a spinal cord stimulator trial. There isno clinical documentationto support medical necessity.The faxed pages to the Plan on July 7, 2020 were blank.Therefore, we decided that the Plan does not have to pre-approvea spinal cord stimulator implantation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6531.You asked the Plan to pre-approvethe compression stockings. You say that the enrollee qualifies.The Plan denied your request. The Plan says the enrollee does not have any covered indications.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over aqualifying wound.The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means that the enrollee does not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6531.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator for the enrollee.
You asked the Plan to pre-approve a spinal electrical osteogenesis stimulator. You say that this is in the best interest of the patient for the healing process. The Plan denied your request. The Plan says that Medicare criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that a spinal electrical osteogenesis stimulator is covered if the above criteria have been 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 a spinal electrical osteogenesis stimulator. Our reviewer says that a spinal electrical osteogenesis stimulator is not considered medically reasonable and necessary in this case. The patient has an odontoid fracture. The existing literature does not support the use of a bone growth stimulator for odontoid fracture healing. It is not needed and it is experimental treatment. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a spinal electrical osteogenesis stimulator. 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 spinal electrical osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefacet joint injections.You asked the Plan to pre-approvethe facet joint injections. You say that you would like reconsideration because you are in extreme pain.The Plan denied your request. The Plan says the records do notshow a medical need for this procedure.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 facet joint injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a lack of an exercise program and physical therapy/spinal manipulation.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 facet joint injections have not been met.Therefore, we decided that the Plan does not have to pre-approvefacet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 29, 2020 by an
out of network (OON) provider.
You asked the Plan to pay for office visit. You say that at the time of service there was no mention that the
provider was out-of-network. The Plan denied your request. The Plan says the denial of payment for this
service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 February 29,
2020 by an out of network (OON) provider.