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

We decided that the Plan does not have to pay for anesthesia for diagnostic or therapeutic nerve blocks and injection (01992) provided October 15, 2020.

You asked the Plan to pay for anesthesia for diagnostic or therapeutic nerve blocks and injection. You say that the services provided were medically necessary. The Plan denied your request. The Plan says this is not a covered service.

The Plan follows Medicare rules. Medicare rules say that unless there is an exception, anesthesia services for intra-articular facet joint injections or medial branch blocks are not routinely reimbursable 

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 anesthesia for diagnostic or therapeutic nerve blocks and injection. Our reviewer says that the requested service was not medically necessary and reasonable Our physician reviewer found the review indicates that the enrollee is a 78-year-old male with a history chronic back pain. The review has determined that there is no clinical rationale for the requested anesthesia services. Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intra-articular facet joint injections or medial branch blocks and are not routinely reimbursable. There were no documented extenuating circumstances to support an exception to the policy. The member was medically stable without any history of high-risk co-morbid conditions to suggest that anesthesia services were warranted

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of anesthesia for diagnostic or therapeutic nerve blocks and injection have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for diagnostic or therapeutic nerve blocks and injection (01992) provided October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of a previous root canal (D3346) and the treatment of a root canal obstruction (D3331) provided on September 30, 2020.

You asked the Plan to pay for the dental services. You say that you do not agree with the denial. The Plan denied your request. The Plan says the services you received are not listed as covered services.

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. Additionally, the record shows that your receipt states that "services are part of the evaluation/treatment are not part of your dental coverage." Therefore, we decided that the Plan does not have to pay for the retreatment of a previous root canal (D3346) and the treatment of a root canal obstruction (D3331) provided on September 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance angiography provided to the enrollee on September 13, 2020 and billed under Claim A.

You asked the Plan to pay for Claim A. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan stated that Claim A denied because the Plan had already paid for this service under another claim. The Plan states the NPI website shows that both providers are listed as diagnostic radiology specialists and both providers work within the same professional practice or group. The Plan states the correct billing of this service needed to include modifier -59 to establish a separate and distinct service was provided.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for magnetic resonance angiography provided to the enrollee on September 13, 2020 and billed under Claim A.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 15, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the
laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation
and/or claim history indicates that the specimen was obtained in an office setting POS 11.

The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting
where the beneficiary receives the face to-face service.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the laboratory services have not been met. Specifically, the claim was billed with a laboratory
place of service code while the record indicates the member's face-to-face service was rendered in an office
setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on
October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 25, 2020.

You asked the Plan to pay for the dental service. You say that the staff at the dentist office does not know how to bill your insurance. You say that you receive bills for services that should be covered. You say that you refuse to pay this bill. You also say that your agent provided you with a print-out of what services are covered and what are not. The Plan denied your request. The Plan says limited oral evaluation is not listed as 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, 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 limited oral evaluation (D0140) provided on November 25, 2020.

Your complaint about the dental office staff is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the copayment for the office visit provided on February 13, 2020.

You asked the Plan to reduce the copayment for the office visit. You say that you were seen by a physician assistant and were only charged $5. You say that you should not be responsible for the $40 specialist copayment. The Plan denied your request. The Plan says that the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $5 copayment for each Medicare-covered primary care visits. 

The Plan says you must pay a $40 copayment for a specialist visit. Based on the Plan contract, however, you cannot be asked to pay more than a $5 copayment for a primary care visit. The billing provider is an emergency medicine physician, which is not considered a specialist. The billing facility is also listed as an internal medicine office. Therefore, we decided that the Plan has to reduce the copayment from $40 to $5 for the office visit provided on February 13, 2020.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray of the neck and spine (72052) provided on July 9, 2020 and billed under Claim A.

You asked the Plan to pay for Claim A. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan stated that Claim A denied because the plan had already paid for this service under another claim. The Plan states the NPI website shows that both providers are listed as diagnostic radiology specialists and both providers work within the same professional practice or group. The Plan states the correct billing of this service needed to include modifier 59 to establish a separate and distinct service was provided. 

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. 

Therefore, we decided that the Plan does not have to pay for an x-ray of the neck and spine (72052) provided on July 9, 2020 and billed under Claim A.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on May 21, 2020.

You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive
order for treatment in place. 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 May 21, 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 May 21,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental surgical services provided to the enrollee on August 31, 2020.

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 the Medicare billing criteria were not met. Maximus overturned the Plans denial for medical necessity. The Plan requested a reopen and stated that the issue was not medical necessity, but that the claim was submitted with an inappropriate code. The Plan states this claim was billed with a primary diagnosis code of C32.1 defined as Malignant neoplasm of supraglottis; which is not covered under the medical benefits. The Plan states the medical this enrollee has been diagnosed with a squamous cell carcinoma to the supraglottic area in his throat as well as the larynx. The case file includes the claim image that shows the billed neoplasm is that of the glottis and supraglottis and not the jaw. The Medicare Benefit Policy Manual in Chapter 16 under General Exclusions from Coverage (Section 140 for Dental Services Exclusion) explains, "The extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease is covered. This is an exception to the requirement that to be covered, a non-covered procedure or service performed by a dentist must be an incident to and an integral part of a covered procedure or service performed by the dentist. Ordinarily, the dentist extracts the patient's teeth, but another physician, e.g., a radiologist, administers the radiation treatments."

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 diagnosis code submitted is not covered under Medicare when submitted via a dental professional. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for dental surgical services provided to the enrollee on August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the thoracic lumbar sacral orthosis provided to the enrollee on July 27, 2020.

You asked the Plan to pay for this orthosis. 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 says that this claim denied because the medical records do not support the service rendered. The Plan states there is no history of an office visit (face to face encounter) conducted to show the ordering provider could have diagnoses or treated the member for any issues/illness for which a brace(s) was needed. The medical records included an order form, exam notes, and letter explaining the need for the items billed, invoice and proof of delivery. However, a review of the member's claim history did not support the medical record provided. The Plan states there was no claim for the office visit or in the last 6 months prior to the date of the service by the ordering/ referring physician. The Plan states that without a Face-to-Face Encounter the ordering physician could not gather the information associated with diagnosing, treating, or managing the clinical condition for which the DMEPOS was ordered. There was no history of an office visit (face to face encounter) conducted to show the ordering provider could have diagnoses or treated this enrollee for any issues/illness for which a brace(s) was needed. The Plan believes this claim should be upheld based on the above findings. In addition, per review of the ordering physician's in-house medical record, the type of records and the signature for the physician do not match to what was submitted by this provider.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. Medicare coverage criteria are not met. Therefore, we decided that the Plan does not have to pay for the thoracic lumbar sacral orthosis provided to the enrollee on July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided from May 27, 2020, to June 3, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the provider is credentialed at this location since May 6, 2020 and an office visit does not require an authorization. The Plan denied your request. The Plan says no prior authorization was 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided from May 27, 2020, to June 3, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) provided on June 15, 2020.

You asked the Plan to pay for the preventive procedure. You say that you believe the enrollee should be reimbursed more for this service. The Plan denied your request. The Plan says this service is not covered.

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 preventive procedure (D1999) provided on June 15, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on January 15, 2021.

You asked the Plan to waive the copayment for an emergency room visit. You say that you received poor care and should not be charged. The Plan denied your request. The Plan says this processed 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 $90 copayment for emergency care visits. 

You have been asked to pay a $90 copayment for an emergency room visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided on January 15, 2021.

Your complaint about the care you received is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the shunt reprogramming provided on November 20, 2020 and December 7, 2020.

You asked the Plan to waive the copayment for the shunt reprogramming. You say that the doctor said you should not be billed for the treatment or observation room for an office visit. The Plan denied your request. The Plan says the copayments 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 $250 copayment for Medicare-covered surgery or other services at an in-network outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $250 copayment for each shunt reprogramming.

Date of Service
Service
Standard Copayment
Member Liability

November 20, 2020
Shunt Reprogramming
$250
$250

December 7, 2020
Shunt Reprogramming
$250
$250

TOTAL:
$500

The shunt reprogramming falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The shunt reprogramming is considered a surgical service. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the shunt reprogramming provided on November 20, 2020 and December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation - per quadrant (D4921 x2) received December 31, 2020.

You asked the Plan to pay for the gingival irrigation. You say that you were told the Plan would cover your cleanings. The Plan denied your request. The Plan says the requested service is not covered under your plan's supplementary benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival irrigation - per quadrant (D4921 x2) received December 31, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided on September 1, 2020, through September 30, 2020.

You asked the Plan to pay for the therapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says one of the codes on this claim was not billed with the required GO modifier.

The Plan must follow Medicare rules. Medicare rules say that the claim must include one of the following modifiers to distinguish the discipline of the plan of care under which the service is delivered: GN, GO or GP. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Specifically, the claim includes an occupational therapy service that was billed with an incorrect modifier. Therefore, we decided that the Plan does not have to pay for the therapy services provided on September 1, 2020, through September 30, 2020.