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

We decided that the Plan does not have to pay for a computed tomography scan of the pelvis provided to the enrollee on August 7, 2020 billed under Claim A.
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. 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 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 a computed tomography scan of the pelvis provided to the enrollee on August 7, 2020 billed under Claim A.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for home health services.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are no records to support the need for an HMO exception.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral out-of-network for home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair options and accessories.

You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the
enrollee's upper limb strength and function are adequate for the enrollee to be able to control power options
using their own switches.

The Plan follows Medicare rules. Medicare rules say that wheelchair options/accessories are only covered
under certain medical indications.

The file shows that a touch screen was requested. The touch screen is included as part of the expandable
control system feature and is unable to be requested separately. A power telescoping foot platform was
requested. This feature is included as part of the approved elevating leg rests. A calf panel was also requested.
The rules say that items must be billed with the proper code. The correct code for the requested calf pad is a
replacement-only code and cannot be requested with the initial chair.

The file shows that an expandable control system was requested. 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 requested items. Our physician reviewer found that the records indicate the enrollee
is independent with eating with 3/5 upper extremity strength. There is documentation that the enrollee's upper
extremity strength is adequate enough to operate the approved power options with their own switches. There is
no documentation that the requested expandable control system is medically reasonable and 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 the requested items have not been met. Therefore, we decided that the Plan does
not have to pre-approve power wheelchair options and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three surgical extractions (D7210 x3), three alveoloplasties in conjunction with extractions (D7311 x3), first 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9239), and three subsequent 15 minute increments of intravenous moderate (conscious) sedation/analgesia (D9243 x3).
You asked the Plan to pre-approve the extractions, alveoloplasties, and intravenous moderate (conscious) sedation/analgesia services. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are 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. The contract lists each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia (D9243) as a covered benefit, but is only covered when it is provided with covered services. Surgical extraction (D7210) and alveoloplasty in conjunction with extractions (D7311) are not covered services, and therefore each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia (D9243) is not covered. Therefore, we decided that the Plan does not have to pre-approve three surgical extractions (D7210 x3), three alveoloplasties in conjunction with extractions (D7311
x3), first 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9239), and three subsequent 15 minute increments of intravenous moderate (conscious) sedation/analgesia (D9243 x3).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the health plan's denial of LTACH coverage should be upheld. The enrollee is
currently undergoing treatment at an ACH following coronary bypass surgery. The enrollee is not
intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.

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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the dispensing plan meets for Part D coverage. The Plan also says that the pharmacy is dispensing the drug to the enrollee to self-administer, or take to the provider.
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 Prolia.
Benefits for Prolia 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upright/stand up walker. You asked the Plan to pre-approve
the walker. You say that this is medically necessary. The Plan denied your request. The Plan says the
notes do not show that the standard four-wheeled walker is not meeting your needs.

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 walker. Our reviewer says that the
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found
the documentation does not reveal that your needs are unable to be met with a standard walker. The
documentation does not reveal that the requested upright/stand up walker would be safe and effective for your
condition.

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 walker have not been met. Therefore, we decided that the Plan does not
have to pre-approve an upright/stand up walker.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ultrasonic guidance for needle placement (76942) and the biopsy or excision of a lymph node (38505) provided on January 24, 2020.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.

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 $110 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility. Additionally, you pay a $50 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. 

You have been asked to pay $118.61 which includes a $68.61 copayment for the diagnostic radiology service provided, which is less than the applicable copayment. Additionally, a $50 copayment was applied for the biopsy service provided by a specialist. 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 copayments for the ultrasonic guidance for needle placement (76942) and the biopsy or excision of a lymph node (38505) provided on January 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 27, 2020.

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 covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test 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 services rendered on July 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for observation services, an echocardiography,
an outpatient surgery, and an emergency room visit provided by a participating provider on December 10,
2019, to May 7, 2020.

You asked the Plan to waive the copayment for observation services, an echocardiography, an outpatient
surgery, and an emergency room visit. You say that you would the Plan to pay for this. The Plan denied your
request. The Plan says the correct charges have been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $350 copayment for outpatient hospital services/observation services, a $45 copayment for
outpatient diagnostic tests/diagnostic services, a $350 copayment for outpatient surgery, and a $90 copayment
for emergency care.

The enrollee has been asked to pay a $350 copayment for observation services, a $45 copayment for an
echocardiography, a $350 copayment for an outpatient surgery, and a $90 copayment for an emergency room
visit. The total amount you are being asked to pay is $835 ($350 + $45 + $350 + $90 = $835). Observation
services falls within the outpatient hospital services/observation services benefit category, an echocardiography
falls within the outpatient diagnostic tests/diagnostic services benefit category, an outpatient surgery falls
within the outpatient surgery benefit category, and an emergency room visit falls within the emergency care
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.

Therefore, we decided that the Plan does not have to waive the copayment for observation services, an
echocardiography, an outpatient surgery, and an emergency room visit provided by a participating provider on
December 10, 2019, to May 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K2 prosthetic foot (L5972, L5986).
You asked the Plan to pre-approve the K2 prosthetic foot. You say that the K2 prosthetic foot is medically necessary. The Plan denied your request. The Plan says the requested prosthetic is beyond the enrollee's functional needs.
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of foot. 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 K2 prosthetic foot. Our reviewer says that the K2 foot is not medically necessary. Our physician reviewer found there is no clinical documentation in the medical records provided to support functional level designated by the prosthetist. The requested K2 components exceed the member's needs. 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 K2 prosthetic foot have not been met. Therefore, we decided that the Plan does not have to pre-approve a K2 prosthetic foot (L5972, L5986).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the health plan's denial of LTACH coverage should be upheld. The enrollee is currently undergoing treatment at an ACH for anemia, chronic renal failure, and bilateral leg wounds. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve surgical placements of implant bodies: endosteal implants (D6010 x12).

You asked the Plan to pre-approve the endosteal implants. You say that you need these endosteal implants approved for coverage. 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 pre-approve twelve surgical placements of implant bodies: endosteal implants (D6010 x12).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do
not have documented skilled nursing needs. You do not have documented skilled therapy needs. You have
likely reached a plateau in function. Daily skilled services are not shown to be required to establish a
maintenance program or to prevent deterioration of your condition. We looked at this physician's review, the
file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care
have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for radiation therapy provided from May 4, 2020, to June 18, 2020.

You asked the Plan to waive the copayments for radiation therapy. You say that you disagree with the charges because you were never charged in the past. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.

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 $60 copayment for therapeutic radiology. 

You received radiation therapy from May 4, 2020, to June 18, 2020, for a total of 22 services. Therefore, you are responsible to pay a $60 copayment per each visit. The total amount you owe is: $60 (copayment) x 22 (radiation therapy visits) = $1,320. 

You have been asked to pay the total copayment amount of $1,320 for radiation therapy. Radiation therapy falls within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for radiation therapy provided from May 4, 2020, to June 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a topical application of fluoride varnish (D1206) and a periodontal medicament carrier with peripheral seal (D5994 x 2).
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says fluoride varnish is not listed as a covered service. The Plan says that periodontal medicament carrier with peripheral seal is not listed as a covered service either.
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 pre-approve a topical application of fluoride varnish (D1206) and a periodontal medicament carrier with peripheral seal (D5994 x 2).