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

 
We decided that the Plan does not have to pre-approve non-emergency air ambulance transport. 
 
You asked the Plan to pre-approve the transport. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered when it is not to an acute care hospital. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
A review of the file shows that the requested services are not emergent and don't meet the criteria for air 
ambulance transport. Based on this information, we decided that Medicare rules for coverage of the transport 
have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergency air 
ambulance transport.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided 
on September 13, 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 September 13, 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 September 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc (J7325). 
 
You asked the Plan to pre-approve Synvisc. The Plan denied your request. The Plan says you have not tried and 
failed the preferred step therapy agent Monovisc and Orthovisc. The Plan also says that there is no indication 
that the preferred agent(s) would likely be less effective, and/or cause adverse effects for you. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc. Our reviewer says that 
Synvisc (J7325) is not medically reasonable and necessary for the enrollee. Our physician reviewer found you 
have not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the 
Plan, requires these be trialed first. Our reviewer found that the documentation does not outline 
contraindications or reasons these medications were not considered. Our physician reviewer also found that 
without the support of the documentation, Synvisc is not approved, as step criteria have not been met. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc (J7325).
Appeal type: Lab
Decision: Favorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on August 19, 2019 and
billed under code G0481.
You asked the Plan to pay for this claim as billed. You say that this testing should be covered by the Plan. The
Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the
Plans denial. The Plan requested a reopen and provided additional information. The Plan stated that this claim
denied because this service does not meet the criteria for the category under which it was billed. After clinical
review of the medical records, the service was determined to be coded incorrectly. This is a billing error on
the part of the provider and the service is not reimbursable. The Plan states the records do not contain
documentation of definitive laboratory results for 8-14 drug classes, including metabolites to support the
coding criteria for G0481. The Plan provided documentation to show only 7 classes had been tested.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, the medical
records for the number of classes tested do not support the services billed. Medicare rules for coverage of this
claim have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided to
the enrollee on August 19, 2019 and billed under code G0481.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on August 4, 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 August 4, 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 August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(S9986). 
 
You asked the Plan to pre-approve the special supplemental benefits. You say that the benefits are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
Medicare does not provide these benefits. The plan's rules apply in this case. The health plan contract states 
that only enrollees with a qualifying diagnosis who are at high risk for hospitalizations or high risk for adverse 
health outcomes are eligible for this benefit. 
 
We looked at the file and the health plan's rules. No records were provided to show that you have a qualifying 
diagnosis. Based on this information, we decided that rules for coverage of the special supplemental benefits 
have not been met. Therefore, we decided that the Plan does not have to pre-approve special supplemental 
benefits for the chronically ill (S9986).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical dental extraction services provided on October 6, 
2020. 
 
You asked the Plan to pay for the surgical dental extraction services. You say that before work began you 
discussed with the doctor your wish to have him do a simple extraction. You say that your tooth was not 
surgically removed, but rather that the typical Novocain injection was followed by the application of a 
clamping device to your tooth and it was yanked out in about 15 seconds. You say that the doctor then 
informed you that the extraction was successful and that he would be proceeding with the implant procedure. 
The Plan denied your request. The Plan says the services in dispute are not a covered benefit under your 
contract. 
 
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 records show that the type of extraction you received was in fact surgical and performed by an Oral 
Surgeon. This surgical extraction was done in conjunction with dental implant services. 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 surgical dental extraction 
services provided on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 1, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or facility. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
service 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 physician's services provided on October 1, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on February 13, 2020 under code 99204. 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. We overturned the Plans denial. The Plan requested a reopen and stated that this claim denied because the provider billed with an invalid diagnosis or condition. The Plan this claim did not include the appropriate primary, first listed or principal diagnosis. The provider has billed with a secondary diagnosis code T50.8X5A for Adverse effect of diagnostic agents, initial encounter as the primary diagnosis in error. The ICD-10-CM Poisoning by, adverse effects of and under-dosing of drugs, medicaments and biological substances (T36-T50) guidelines explains: "When coding an adverse effect of an drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug (T36-T50) The code for the drug should have a 5th or 6th character "5" (for example T36.0X5)". The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due the omission of a primary diagnosis code. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on February 13, 2020 under code 99204.
Appeal type: Lab
Decision: Favorable

We decided that the Plan does not have to pay forlab services provided to the enrollee on March 24, 2020 and billed under codes 36415 and 80048.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan says that this claim denied  because  thechargeexceedsthe feescheduleor maximum allowable or contracted/legislated fee arrangement. The Plan states the provider billed the claim inappropriately with the incorrect Revenue Code. The provider has billed with Revenue Code 0300 for "Laboratory-General". The Plan states the provider needed to bill with Revenue Code 0510 for "Clinic-General classification". The Plan provided the claims to show this error. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the claim cannot be paid as billed due to an incorrect revenue code billed on the claim. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forlab services provided to the enrollee on March 24, 2020 and billed under codes 36415 and 80048
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forTempus "xT" Gene Testing provided to the enrollee May 1, 2020.You asked the Plan to pay forthis testing. You say that this testing was medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.Our Medical Director looked at the case file and the reopen request. At issue is coverage for Tempus "xT"genetic panel testing.The Maximus Physician Reviewer the documentation supports that the enrollee in this case has advanced stage III or IV cancer andhas decided to seek further cancer treatment. There is no indication that the enrollee hadbeen previously tested using the same NGS test for the same primary diagnosis of cancer.The Plan requested a reopen and stated that the Maximus Physician Reviewer did not address the fact the test does not have FDA approval as required for coverage under the NCD. The Plan stated the reviewer did not address that for coverage under the MAC, tests are required to register test services on the DEX Diagnostics Exchange and submit a complete technical assessment. The Plan stated that Tempus is not registered on DEX and has not submitted a technical assessment.Our Medical Director says the Plan is correct in this case. Our Medical Director says that the medical records show the enrollee had a diagnosis of high-grade invasive and metastatic urothelial carcinoma.The Plans denial in this case was not based on medical necessity.  Rather, it was based on the fact that this specific test does not have FDA clearance.  The rules are clear that these tests require the labs to submit to MolDX to complete a technical assessment. The Plan has clearly laid out that this lab has not done so with this particular test.  Without a completed and approved technical assessment under the MolDX program, this test is not eligible for coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this testing have not been met.Therefore, we decided that the Plan does not have to pay forTempus Gene Testing provided to the enrollee May 1, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan does not have to provide coverage for inpatient admission for the enrollee.
You asked the Plan to provide coverage for acute inpatient hospital care. You say that inpatient admission is
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an inpatient
admission. The Maximus Physician Reviewer determined that the records show the concern was it was not safe
for the enrollee to be at home and there was no safe place at the time for disposition. The Plan requested a
reopen and stated that the records show the family brought the enrollee to the emergency department purely for
custodial care and or placement. The medical records show the enrollee has a history of dementia and her
husband and primary care giver was hospitalized at the time. The family brought her to the emergency room as
it was felt she could not stay at home. However, the physical examination was unremarkable. The lab work was
unremarkable. The enrollee was in good behavioral control without agitation, delirium or behavioral
disturbance. The ED physician notes state "This seems to be strictly a custodial admission given her unsafe
discharge planning. There are no medical reasons presently to admit the patient."
Our Medical Director finds the Plan is correct in this case. The documentation does not support that inpatient
services were medically reasonable and necessary for the enrollee in this case. We looked at this physician's
review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of
acute inpatient hospital care have been met. Therefore, we decided that the Plan does not have to provide
coverage for inpatient admission for the enrollee.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan does not have to pay forambulancetransport provided to the enrollee on April 30, 2020 and billed with codesA0425 and A0427.You asked the Plan to pay forthis claim as billed. 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 information. The Plan states that this claim denied because the provider billed with an invalid diagnosis or condition. The Plan states this claim billed with diagnosis  code T50.905A for "Adverse  effect  of  unspecified  drugs,  medicaments  and  biological  substances,  initial  encounter  as  the  primary  diagnosis." The Plan states thisdiagnosis code is a secondary only diagnosis which cannot beused as the primary, first listedor principal diagnosis for any procedure or service.The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the claim was not billed with an appropriate primary diagnosis code. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay forambulance transport provided to the enrollee on April 30, 2020 and billed under claim 820201270191001 with code A0425 and A0427.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan with contrast and
coronary calcium (Code 75571).
You asked the Plan to pre-approve a CT scan with calcium scoring. You say that this imaging is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
coverage criteria.
Our Medical Director looked at the case file and the reopen request. Our Medical Director says that at issue is
coverage for a CT scan of the heart. The Maximus Physician Reviewer determined that the results of a
coronary CT scan would change therapy if the coronary calcium score was elevated. The medical literature
supports its use in this circumstance. CT Scan of the coronary arteries was determined to be medically
reasonable and necessary. The Plan requested a reopen and stated the issue was not medical necessity, but the
fact that the service in of itself is not covered. Our Medical Director reviewed the Medicare regulations and
determined the Plan is correct in this case. The requested service is not covered for screening purposes.
Medicare coverage criteria were not met. We looked at this physician's review, the file, and Medicare rules.
Based on this information, we decided that Medicare rules for coverage of a CT scan with CPT Code 75571
have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography
(CT) scan with contrast and coronary calcium (Code 75571).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pre-approvecomputed tomography (CT) scan of the heart for the enrollee with evaluation of coronarycalcium (75571).You asked the Plan to pre-approveCT scan of the heart with evaluation of coronary calcium. You say that this imaging is medically necessary for the enrollee.The Plan denied your request. The Plan says the requested service is not covered by Medicare. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct Medicare coverage criteria.Our Medical Director looked at the case file and the reopen request. At issue is coverage for a CT scan of the heartwith evaluation of coronary calcium. The Maximus Physician Reviewer determined that CT coronary calcium evaluation is reasonable in this case. The Plan requested a reopen and stated that medical necessity was not the issue, the issue was the code requested and the service requested are not covered by Medicare. Our Medical Director review the service requested and the Medicare rules. The Plan is correct in this case. The requested service (CPT code 75571-Cardiac CT with evaluation of coronary calcium) is a non-covered service per the Medicare LCAguidelines. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan of the heart with evaluation of coronarycalciumhave not been met.Therefore, we decided that the Plan does not have to pre-approvecomputed tomography (CT) scan of the heart for the enrollee with evaluation of coronary calcium (75571)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's servicesprovided on October 13, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions,while you are a member of our Plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgentlyneeded services when the Plan'snetwork is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.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 Plandid not pre-approve the physician's services. 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 physician's servicesprovided onOctober 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea pneumatic compression device (E0652, E0667) for the enrollee.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no documentation substantiating use of a compression garment with a minimum of 30 mmHg distally.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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee has objective physical exam findings of lymphedema of the chest, trunk, or abdomen. There is no evidence of unique characteristics that would indicate the segmented pump over a standard pump. There is nodocumentation of a trial and failure of the standard pump.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 device have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea pneumatic compression device (E0652, E0667) for the enrollee.