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

We decided that the Plan does not have to pay for the laboratory services provided on November 30, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on February 18, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing. You say that the service is medically necessary. 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows the drug testing was done during an office visit which means the provider had the opportunity to confirm insurance coverage and authorization. Therefore, we decided that the Plan does not have to pay for the drug testing provided on February 18, 2020 by an out-of-network (OON) provider
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services rendered on December 9, 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 procedure code 99285 is not supported.
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 99285 is Level 5 emergency department visit for
evaluation and management of patient with problem immediately threatening life, including comprehensive
history and physical examination, and medical decision-making of high complexity.
We find that CPT code 99285 is not supported in the medical record. Specifically, the records do not support
Level 5 emergency room care. Based on this information, we decided that Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room
services rendered on December 9, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department services to treat gingivitis provided on April 17, 2021.
You asked the Plan to pay for the emergency department services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says these dental services are not covered by Medicare or the Plan.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the emergency department services to treat gingivitis provided on April 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity orthosis.
You asked the Plan to pre-approve powered upper extremity orthosis. You say that this device meets the functional needs of the enrollee. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the records do not cite failure of specific modalities and/or devices used in rehabilitation and the enrollee has contraindications to this device.
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 powered upper extremity orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was evaluated by her physician on June 9, 2021 for an annual visit. The clinical documentation does not include a physician examination of the upper extremity. The plan does not include use of this upper extremity device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of powered upper extremity orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on April 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the physician services. You say that the services are medically necessary. 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 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 physician services provided on April 30, 2021 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 limited oral evaluation provided on April 24, 2021.

You asked the Plan to pay for the limited oral evaluation. You say that you have a $3,000 benefit and only used $506. You say that payment should be adjusted and $64 should be allocated to the service. The Plan denied your request. The Plan says code D0140 is only allowed one procedure every three plan years.

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, you also have a maximum benefit of one limited oral evaluation every year. The Plan paid for a limited oral evaluation provided on March 30, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation provided on April 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by an out-of-network (OON) provider from March 18, 2021 to April 27, 2021.

You asked the Plan to pay for the dental services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental services are not covered when provided by an OON provider.

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 dental services received are not among those covered under this benefit when provided by an OON provider. Therefore, we decided that the Plan does not have to pay for the dental services provided by an out-of-network (OON) provider from March 18, 2021 to April 27, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (ECG) represented by code 93010 provided on February 8, 2021.
You asked the Plan to pay for code 93010. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says code 93010 is considered as a bundled service with the emergency department visit 99285 that was billed under the same claim.
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, we have confirmed that code 93010 has a bundled relationship with code 99285 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (ECG) represented by code 93010 provided on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI)
joint.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the records show that you have bilateral
sacroilitis. You had two sets of bilateral SI joint injections with 80 percent pain relief that lasted for two weeks.
The RFA now being requested is considered experimental/investigational in nature due to wide variation in
effectiveness. The services are therefore not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Local Coverage Article (LCA) A52863 referenced by the Plan is not relevant to the services at issue and was
not used in the MAXIMUS determination
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a retainer crown (D6740), and pontic (D6245) provided on April 15, 2021.

You asked the Plan to pay for a retainer crown, and pontic. You say that the services were necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits.

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 a retainer crown (D6740), and pontic (D6245) provided on April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup provided on February 3, 2021 and the intraoral x-rays provided on February 23, 2021.
You asked the Plan to pay for the intraoral x-rays and core buildup. You say that you were informed you had an infection and to make an endodontics appointment to treat the infection. You say that the appeal should be granted. The Plan denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the core buildup provided on February 3, 2021 and the intraoral x-rays provided on February 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the cane provided on March 3, 2021.
You asked the Plan to pay for the provided item. You say that you were advised not to walk without using your cane. The Plan denied your request. The Plan says they cannot pay a provider who has opted out of or been excluded from Medicare.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you receive your care from a provider who is eligible to provide services under Original Medicare.
We looked at the file and the rules. The case file does not indicate the provider at issue is eligible to provider services under Original Medicare. Based on this information, we decided that the rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the cane provided on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services provided on November 18, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says medical records are still needed.
The Plan must follow Medicare rules. Medicare rules say that providers must furnish sufficient information to determent whether payment is due. In this case, the CPT Code Manual definition of code 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. In this case, there is insufficient documentation to show the services were provided on the date of service. The file shows the enrollee requested medical records for the date of service at issue, but none was obtained. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services provided on November 18, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the gene panel provided on December 8, 2020.

You asked the Plan to pay for the testing services. You say that the test was necessary to assist in the treatment and diagnosis of the enrollee's cancer. The Plan denied your request. The Plan says coverage is limited to one test per specimen.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We looked at the file and the rules. If a single procedure is performed, only one code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the gene panel provided on December 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on March 4, 2021.

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 procedure codes S1015 and S8301 are not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. 

We looked at the file and Medicare rules. Billed procedure codes S1015 (IV tubing extension set) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the supplies rendered on March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 11, 2021.
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 services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, 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 February 11, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found a minimum of three physical tests (such as thigh thrust, sacral compression, and FABER) need to be documented before an SI joint injection is considered. Findings for these tests are not documented; therefore, the SI joint injection is not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services rendered on June 5, 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 services from a non-network provider 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. The Plan covers supplemental dental benefits from a network provider only.

We looked at the file and Medicare rules. The file shows that you received services from a provider not in the Plan's dental network. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the dental services rendered on June 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital services rendered on January 4, 2021 to January 27, 2021.

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 procedure codes 99223, 99232, 99238, and 99233 are not supported.

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 99223 is Level 3 initial hospital care for evaluation and management of patient with problem of high severity, including comprehensive history and physical examination, and medical decision-making of high complexity, typical time 70 minutes. The definition of code 99232 is Level 2 subsequent hospital care for evaluation and management of patient, including expanded problem-focused interval history and medical decision-making of moderate complexity, typical time 25 minutes. The definition of code 99238 is hospital discharge day management; 30 minutes or less. The definition of code 99233 is Level 3 subsequent hospital care for evaluation and management of patient, including detailed interval history and medical decision making of moderate complexity, typical time 35 minutes.

We find that CPT codes 99223, 99232, 99238, and 99233 are not supported in the medical record. Specifically, there is no documentation of Level 3 initial hospital care for 70 minutes to support code 99223. There is no documentation of Level 2 subsequent hospital care for 25 minutes to support cod 99232. There is no documentation of 30 minutes or less of discharge services to support code 99238. There is no documentation of Level 3 subsequent hospital care for 35 minutes to support code 99233.

Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital services rendered on January 4, 2021 to January 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 enrollee is receiving appropriate care at the present acute care hospital and does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. 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. Specifically, medically necessary services are being obtained at the enrollee's current level of care and they do not require any additional
services. This means admission into a LTACH is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services