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

We decided that the Plan does not have to pre-approve insertion of Vertiflex Superion device (CPT code 22869), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.

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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has degrees of spinal stenosis (including "severe") not at FDA indicated levels of "moderate" spinal stenosis. MRI report was not provided to corroborate documented findings on exam. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. Detailed documentation is not evident regarding discussion of spinal instability, as there are no provided flexion/extension films. Detailed documentation is not evident regarding discussion of scoliosis. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this patient. Therefore, the request for Vertiflex Superion Device is not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of Vertiflex Superion device (CPT code 22869), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transport from dialysis to residence.

You asked the Plan to pay for the non-emergent ambulance transport. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee appears to be able to sit in a wheelchair or recliner therefore alternatives to transport may include a wheelchair van or a private vehicle.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

We looked at the file and Medicare rules. The record shows the enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. The enrollee could have been safely transported by another type of vehicle. You did not request prior authorization. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transport from dialysis to residence.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for out-of-network services provided on August 19, 2020.

You asked the Plan to pay for out-of-network services. The Plan denied your request. The Plan says that prior authorization was not requested.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit an explanation of benefits or claim form showing the billed services or the full Evidence of Coverage. This means that we cannot determine if the denial for non-authorized services is justified. Therefore, we decided that the Plan has to pay for out-of-network services provided on August 19, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (CPT code 20939), for the enrollee.

You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have NOT been demonstrated in the peer-reviewed literature.

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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental for use in cases of spinal fusion surgery. More research is needed to show safety and efficacy. 

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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (CPT code 20939), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided by an out of network (OON) provider.

You asked the Plan to pay for the vision services. You say that you did not know this provider was out of network. The Plan denied your request. The Plan says that you must receive care from a network provider.

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 vision services provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray technical component and transportation/setup charges for mobile radiology services provided on August 13, 2020.

You asked the Plan to pay for the technical component, transportation, and setup charges. You say that these services were medically necessary and should be covered. The Plan denied your request. The Plan says the services billed cannot be paid in the reported POS.

The Plan must follow Medicare rules. Medicare rules say that POS 31 is reported for enrollees in a Part A covered SNF stay. The technical component and transport/setup for mobile radiology services cannot be separately billed for a patient in a covered SNF stay. 

The POS reported in this case was 31. The billed codes are not separately payable with this POS code. Therefore, we decided that the Plan does not have to pay for the x-ray technical component and transportation/setup charges for mobile radiology services provided on August 13, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on November 18, 2020.

You asked the Plan to pay for the laboratory testing. You say that the provider has no knowledge of the enrollee's coverage prior to the arrival of the specimen to the lab. You say that the provider should not be penalized for being out of network as we continue to do our part in providing timely testing and results to the Covid-19 pandemic. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on November 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 services provided to the enrollee by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV tubing extension set (S1015) and infection control supplies (S8301).

You asked the Plan to pay for the IV tubing extension set and infection control supplies. You say that you would like reconsideration because you provided the service at a reduced medical cost for which you remain unpaid. The Plan denied your request. The Plan says CPT codes S1015 and S8301 have a status indicator of I and are not valid for Medicare purposes.

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 find that CPT codes S1015 and S8301 are not supported in the record. Specifically, per the Physician Fee Schedule, CPT codes S1015 and S8301 have a status indicator of I. This means that CPT codes S1015 and S8301 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the IV tubing extension set and infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for the IV tubing extension set (S1015) and infection control supplies (S8301).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services rendered on July 12, 2019.

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 claim was not filed timely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for these services was not filed until December 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the physician services rendered on July 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating
hospital.

You asked the Plan to waive the copayment for lab work. You say that this was not at a hospital, this was in an
office. The Plan denied your request. The Plan says the correct copayment has 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). Your contract with the Plan clearly says that you must pay a $50
copayment for outpatient diagnostic tests/in-network/lab services/outpatient hospital.

You have been asked to pay a $50 copayment for lab work. Lab work falls within the outpatient diagnostic
tests/in-network/lab services/outpatient hospital 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 lab work provided by a participating hospital.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a dual-energy X-ray absorptiometry (DXA), bone density study.

You asked the Plan to pay for the dual-energy X-ray absorptiometry (DXA), bone density study. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a dual-energy X-ray absorptiometry (DXA), bone density study.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee code 99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour) billed to the enrollee for date of service September 14, 2020.

You asked the Plan to pay for this claim. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says , the documentation shows 46 minutes of direct patient care in discussions with the family and other providers by telephone, as well as care that may have been before or after the direct patient care (reviewing records and communicating recommendation to other providers), however the time spent for this care is not separated from the direct patient care. The Plan states that this service should be billed entirely as direct patient care.

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, payment for this service would be bundled under another code. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for code 99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour) billed to the enrollee for date of service September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on June 4, 2020.

You asked the Plan to pay for foot orthotics. You say that you have pain from severe pronation of both feet.
The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on June 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for inpatient admission for knee surgery for the enrollee.

You asked the Plan to provide coverage for acute inpatient hospital care. You say that inpatient admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for inpatient admission for an enrollee undergoing left hip arthroplasty. The Maximus Physician Reviewer determined that the enrollee had sufficient comorbid conditions that the total hip arthroplasty needs to be performed as inpatient status. The Plan argues that the enrollee did not have active or uncontrolled comorbidities, and there was no indication that inpatient status should have been improved preemptively.

The medical records show the enrollee was a then 67-year-old woman with hypertension and a high body mass index. Our Medical Director has concluded that the Plan is correct in this case. The documentation does not support that it was reasonable for the admitting physician to preemptively expect that the enrollee's necessary hospital care would span two midnights. Medicare criteria for inpatient admission were not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to provide coverage for inpatient admission for knee surgery for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided by an OON provider.

You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that you were not advised that a specific dentist had to provide the services to be covered in-network. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that services performed by non-participating dentists 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 covered when they are received OON. The record shows there is no conversation between you and the Plan where you were advised you could go to any dentist at the facility. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on January 27, 2020, February 26, 2020 and April 20, 2020.

You asked the Plan to pay for laboratory services. You say that medical records were submitted. You say that the claims should be reprocessed and paid. The Plan denied your request. The Plan says in-network providers were available.

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 laboratory services provided by an out-of-network provider on January 27, 2020, February 26, 2020 and April 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography angiography (CTA) of the chest, heart, and coronary arteries without contrast with quantitative evaluation of coronary calcium (75571).

You asked the Plan to pre-approve the computed tomography angiography. You say that you have heart problems and needs this procedure done as soon as possible. The Plan denied your request. The Plan says the clinical information provided does not meet the medically necessary criteria.

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 computed tomography angiography. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, there are no signs or symptoms of cardiac disease. The requested test is for screening purposes. Screening tests are an exclusion under the local coverage determination. The requested service cannot be recommended. 

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 computed tomography angiography have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography angiography (CTA) of the chest, heart, and coronary arteries without contrast with quantitative evaluation of coronary calcium (75571).