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

We decided that the Plan does not have to waive the copayments for ultrasounds.

You asked the Plan to waive the copayments for ultrasounds. You say that the Plan always covered your copayments in the past and you disagree with the charges. 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 $160 copayment for each ultrasound.

You received ultrasounds, for a total of 4 ultrasounds. Therefore, you are responsible to pay the total allowed amount of $437.24, which is less than the total copayment amount.

You have been asked to pay $437.24 for ultrasounds. Ultrasounds fall 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 ultrasounds.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nail debridement (11721) provided in a hospital outpatient clinic.

You asked the Plan to waive the copayment for nail debridement. You say that you should not be charged this amount because you were only there for a few minutes. 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 $450 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You have been asked to pay a $231.75 copayment for nail debridement, which is considered a surgical service, because the allowed amount is less than $450. 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 nail debridement (11721) provided in a hospital outpatient clinic.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection (87798).

You asked the Plan to pay for infectious agent detection. You say that this test was ordered by the physician. The Plan denied your request. The Plan says this test was performed for screening purposes.

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, infectious agent detection, 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 infectious agent detection (87798).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic services provided by an out of network provider.

You asked the Plan to pay for screening digital breast tomosynthesis (77063) or screening mammography (77067). You say that the Plan should pay this claim. The Plan denied your request. The Plan says prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 diagnostic services provided by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram.

You asked the Plan to pay for electroencephalogram (EEG). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 95819 is Electroencephalogram (EEG); including recording awake and asleep.

We find that CPT code 95819 is not supported in the medical record. Specifically, the record shows the enrollee was comatose during the study. Based on this information, we decided that Medicare rules for coverage of electroencephalogram (EEG) have not been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an intravenous infusion.

You asked the Plan to waive the deductible for an intravenous infusion. You say that you disagree with the charges. 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. Your contract with the Plan says that there is a $1,000 deductible for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.

The record shows that you received an intravenous infusion at an outpatient hospital facility. The record shows that you had only paid $135.78 prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $222.60.

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time an intravenous infusion. Therefore, we decided that the Plan does not have to waive the deductible for an intravenous infusion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for simple wound repair (12001).

You asked the Plan to pay for the simple wound repair. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says billed procedure code 12001 supports one unit of service for the billed date of service and the provider billed two units.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 12001 is one. You billed two units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the simple wound repair have not been met. Therefore, we decided that the Plan does not have to pay for simple wound repair (12001).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic screening testing.

You asked the Plan to pay for genetic tests. You say that your lab performed the tests ordered by the referring physician. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not covered for the diagnosis billed and was performed for screening purposes.

The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services.

We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the billed testing. Without an order, it has not been shown that this testing was performed for a covered diagnostic indication. Based on this information, we decided that Medicare rules for coverage of genetic tests have not been met. Therefore, we decided that the Plan does not have to pay for molecular genetic screening testing.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a PET/CT scan for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that this study is not supported for the first staging of prostate cancer.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found while PET/CT is not usually covered for routine prostate cancer staging, the enrollee has multiple areas of concern on CT imaging. Any or all of these lesions could be metastatic and therapy will depend on whether they reflect metastatic disease of cancer of the prostate. The best single test to determine the nature of each of these areas of concern is a prostate specific test which is a PET/CT Axumin exam.

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 scan have been met. Therefore, we decided that the Plan has to pre-approve a PET/CT scan for the enrollee.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transport.

You asked the Plan to waive the copayment for the ambulance transport. You say that this service should be covered in full because it was medically necessary. The Plan denied your request. The Plan says you were charged this copayment 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 ambulance services.

You have been asked to pay a $325 copayment for the ambulance transport. This copayment applies regardless of the reason for the transport. 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 ambulance transport.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Faslodex (J9395) for the enrollee.

You asked the Plan to pre-approve Faslodex (J9395). You say that Faslodex (J9395) 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. Our Medical Director says at issue is coverage for Faslodex (Fulvestrant). The Maximus Physician Reviewer determined that treatment of hormone-receptor (HR)-positive advanced breast cancer in postmenopausal women with disease progression following endocrine therapy is approved and appropriate. The Plan requested a reopen and argued that for the enrollee's condition, subsequent therapy with combination fulvestrant/anastrozole for hormone receptor (HR)-positive, HER2-negative recurrent breast cancer, do not have support in a Medicare-accepted compendia and Medicare-accepted medical journals. The Plan states that per NCCN Guidelines for Breast Cancer, single agent fulvestrant or fulvestrant in combination with a CDK4/6 inhibitor would be appropriate treatment options. Our Medical Director states that the medical records show the enrollee is a 67-year-old woman with a diagnosis of "ER+ clinical stage IIIA highly proliferative breast cancer", with micrometastases. The records show the cancer progressed while being treated with Letrozole, and then had good response to chemotherapy. Surgery was followed by treatment with Xeloda. Our Medical Director has concluded that the Plan is correct in this case. There is insufficient evidence to support the use of Faslodex (Fulvestrant) with Anastrozole. Medicare coverage criteria are 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 Faslodex (J9395) have not been met. Therefore, we decided that the Plan does not have to pre-approve Faslodex (J9395) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on October 1, 2020.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that these services should be covered under the Non-Medicare covered preventive dental services listed in the Evidence of Coverage. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective November 17, 2015, to November 17, 2021. The Plan also says that charges incurred by Medicare opt out providers will not be reimbursed by the 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 periodic oral evaluation, bitewing x-rays, and prophylaxis provided on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2393) provided on November 6, 2020.
You asked the Plan to pay for the resin-based composite. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that you were not enrolled in for the year 2020.
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 resin-based composite (D2393) provided on November 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit you had with a colorectal surgery nurse practitioner.

You asked the Plan to waive the deductible for the office visit. You say that you should only have to pay the specialist copayment because this was just a pre-op visit for a colonoscopy. The Plan denied your request. The Plan says you were charged this deductible 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 there is a $500 deductible for covered medical services.

The annual deductible applies to all covered medical services, including office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for covered medical services. This cost sharing is a contractual obligation that had not been met at the time the office visit. Therefore, we decided that the Plan does not have to waive the deductible for the office visit you had with a colorectal surgery nurse practitioner.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses provided on September 24, 2020.
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says you have exceeded the eyewear allowance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The records show that the plan paid $150 for the provided eyeglasses, which allowed you to meet the maximum benefit. Therefore, we decided that the Plan does not have to further pay for the eyeglasses provided on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology exam and retina treatment provided on January 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the services provided. You say that you are in network. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 ophthalmology exam and retina treatment provided on January 13, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on October 9, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because you thought all copayments were waived. 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 $30 copayment for each specialist visit. You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on October 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis (L0648) provided June 10, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the item provided was medically necessary for the enrollee. The Plan denied your request. The Plan says they have insufficient documentation to corroborate the services provided.
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 relevant medical records which support medical necessity for the supplies provided in this case. The medical records included support the request for a lumbar-sacral orthosis coded as L0361 which is different than the orthosis that was delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis (L0648) provided June 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there are no indications for skilled nursing or skilled rehabilitation at a skilled nursing facility level of care.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.