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

We decided that the Plan does not have to pay for the services (CPT 99213) provided on October 22, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is included in surgery payment.
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global surgery procedures includes payment for the above services related to the surgery when furnished by the physician who performs the surgery. We looked at the file and Medicare rules. The office visit in question was provided within the 90-day global period for the surgical procedure (CPT 27880) on August 31, 2019. This means that payment for this visit is included in the payment for the surgical procedure. 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 the services (CPT 99213) provided on October 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for eye surgery provided on May 6, 2019.You asked the Plan to waive the copayment for eye surgery. You say that you only had one surgery which you paid for. The Plan denied your request. The Plan says the copayment applied correctly.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 $325 copayment for all other outpatient services including observation and outpatient surgical services not provided in an ambulatory surgical center.You have been asked to pay a $325 copayment for the eye surgery. The eye surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that surgery was performed. 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 eye surgery provided on May 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing provided on September 4, 2019.
You asked the Plan to pay for the testing services. You say that the testing is used to determine the best therapy option for late stage cancer patients. The Plan denied your request. The Plan says the testing is a non-covered service.
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 testing services. Our physician reviewer found that the enrollee was diagnosed with squamous cell cancer of the lung. Testing specifically related to squamous cell cancer of the lung and for which associated therapies are known, is medically necessary and reasonable. Panel testing, inclusive of testing that is not related to squamous cell cancer of the lung or for which there are no associated therapies, is not medically necessary or reasonable. The documentation does not support that the requested panel testing was medically necessary or reasonable to diagnose, treat or manage the enrollee's lung cancer. 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 testing services have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing provided on September 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removable prosthodontic procedure (D5899), first 15 minutes of intravenous moderate (conscious) sedation (D9239), and two subsequent 15 minute increments of intravenous moderate (conscious) sedation (D9243 x2) provided on February 17, 2020.You asked the Plan to pay for the removable prosthodontic procedure and sedation services. You say that you spoke with the Plan and were advised that these services were covered.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 removable prosthodontic procedure (D5899), first 15 minutes of intravenous moderate (conscious) sedation (D9239), and two subsequent 15 minute increments of intravenous moderate (conscious) sedation (D9243 x2) provided on February 17, 2020.
Appeal type: Inpatient Hospital
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 from March 11, 2020, to March 18, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 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 from March 11, 2020, to March 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora passive motion device (E0935) provided January 25 to February 12, 2020.You asked the Plan to waive the coinsurance forthe passive motion device. You say that the coinsurance should be waived.The Plan denied your request. The Plan says the correct cost-sharing 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 18% coinsurance for durable medical equipment. You have been asked to pay a 18% coinsurance for the passive motion device. The passive motion device falls within the durable medical equipment 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 coinsurance fora passive motion device (E0935) provided January 25 to February 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe vaccinations provided on February 11, 2020.You asked the Plan to pay forthe preventative vaccinations. You say that you were going out of town and you had your doctor give you some shots.The Plan denied your request. The Plan says preventative vaccines are not covered under your Medicare Part B benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the preventative vaccinations. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the preventative vaccinations.Therefore, we decided that the Plan does not have to pay forthe vaccinationsprovided on February 11, 2020.Benefits for the preventative vaccinationsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea heavy-duty hospital bed.You asked the Plan to pre-approvethe heavy-duty hospital bed. You say that the pressure-reducing mattress that was provided on May 11, 2020 needs to be exchanged for a heavy-duty bed because the enrollee is tall.The Plan denied your request. The Plan says under Medicare guidelines the requested item is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed is only covered when a beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds.We looked at the file and Medicare rules. The records show that the enrollee's most recently noted weight was 160 pounds. Based on this information, we decided that Medicare rules for coverage of the heavy-duty hospital bed have not been met.Therefore, we decided that the Plan does not have to pre-approvea heavy-duty hospital bed.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (epoetin alfa).
You asked the Plan to pre-approve Procrit. The Plan denied your request. The Plan says epoetin alfa is contraindicated in patients with uncontrolled hypertension.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Procrit. Our physician reviewer found that the enrollee has multifactorial anemia. He has stage 3 chronic kidney disease. His hemoglobin is 10.5 Procrit is not initiated unless the hemoglobin is less than 10. The service is not reasonable or medically necessary at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit (epoetin alfa).
Appeal type: Outpatient Mental Health
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 13, 2020. You asked the Plan to pay for the services. You say that you were told this provider was in-network. The Plan denied your request. The Plan says the 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 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 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care.You asked the Plan to pre-approve home health care. The Plan denied your request. The Plan says you are not completely homebound, or in need of skilled nursing services.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 home health care. Our physician reviewer found that you are noted to be independent with ambulation, transfers, and activities of daily living. You have no wounds. The records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition; or to establish/perform a maintenance program to maintain your condition or prevent deterioration. You have no complex wounds. You are not home bound. You do not need to have home skilled nursing services for lab draws or to instruct on insulin injection or disease management. Therefore, the requested services are 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 home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says services can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's current medical status does not require intensive physician or nursing oversight in an IRF. You may benefit from additional multiple therapies; however, your functional level does not require or indicate that this therapy must be in an IRF with an intensive level program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the gastrointestinal pathogen (GIP) multiplex panel rendered
on December 12, 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 the testing is not supported.
The Plan must follow Medicare rules. The rules say that Medicare is establishing limited coverage for
procedure code 87507.
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 87507 with
diagnosis codes R19.5, R19.7, and K510.11. The claim was not billed with the required dual diagnosis code for
which Medicare has established limited coverage. Therefore, we decided that the Plan does not have to pay for
the gastrointestinal pathogen (GIP) multiplex panel rendered on December 12, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the medical services provided on January 8, 2020, by an out-of-network provider.
You asked the Plan to pay for the out-of-network services. You say that the documentation supports treatment at the level of care billed. The Plan denied your request. The Plan says that certification is required for all services from a non-contracted provider.
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. MAXIMUS requested Plan contract information for the services at issue, with no response. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the medical services provided on January 8, 2020, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and diagnostic testing provided on February 20, 2020.
You asked the Plan to pay for the testing services. You say that the codes are supported by the physicians custom profile. The Plan denied your request. The Plan says the billed services cannot be verified.
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 code is not supported in the medical record. The records do not show that the ordering physician is treating the enrollee for a specific medical problem. The records provided do not document concerns based on clinical review and judgement. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and diagnostic testing provided on February 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom ankle-foot orthotic and support items.
You asked the Plan to pre-approve the custom ankle-foot orthotic and support items. You say that The Plan denied your request. The Plan says the information received does not support the medical necessity for the requested items.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules also say that information must be supplied by the requestor that corroborates the information in the enrollee's medical records and that confirms Medicare coverage criteria have been met. We looked at the file and Medicare rules. The case file shows that no clinical information or medical records were submitted, despite the Plan's request for this necessary documentation. Without this documentation we are unable to evaluate whether the requested items are medically necessary. Based on this information, we decided that Medicare rules for coverage of the custom ankle-foot orthotic and support items have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom ankle-foot orthotic and support items.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on February 3, 2020.You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on November 27, 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 the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that the QZ modifier is billed for CRNA services with the AA modifier billed by the physician to represent two medically necessary services.We looked at the file and Medicare rules. The provider billed procedure code 01936 with modifier QZ. The file does not show that physician services were also billed with the AA modifier. 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 anesthesia services rendered on November 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power scooter.You asked the Plan to pre-approvea power scooter. You say that this is medically necessary for you.The Plan denied your request. The Plan says that scooters for use in the community are not covered by Medicare.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on December 20, 2019.You asked the Plan to pay for the complete series of intraoral x-rays. You say that you did not know that you were limited to one x-ray per year. You also say that you are on a fixed income and cannot afford to pay this bill.The Plan denied your request. The Plan says the benefits for this service have been satisfied and the frequency limitation has been exceeded.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, complete series of x-rays is limited to one procedure every five years. The record shows that you received a complete series of intraoral x-rays on February 19, 2019 and your full mouth or panoramic x-rays benefit has been exhausted.Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on December 20, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided on September 17, 2019 through September 20, 2019.
You asked the Plan to pay for the hospital services. You say that you would like reconsideration because the Plan needs to process as a secondary cross-over. The Plan denied your request. The Plan says the policy benefits have been exhausted.
The Plan must follow Medicare rules. Medicare rules say that Medicare secondary payment is the gross amount payable by Medicare minus the applicable Medicare deductible and coinsurance amounts. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. Specifically, the Plan's liability is $0 after the payment from the primary payor. Therefore, we decided that the Plan does not have to pay for hospital services provided on September 17, 2019 through September 20, 2019.