Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on March 26, 2020.
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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on March 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80048, 81001, 85025, 87086,
and P9604 provided from June 1, 2019, to August 5, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services coded are not supported by the documentation.
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 80048, 81001, 85025, 87086, and P9604 are not supported in the medical record.
Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when
the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a
laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates
that the specimen was obtained in an office setting place of service 31. Based on this information, we decided
that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the
Plan does not have to pay for the laboratory services coded 80048, 81001, 85025, 87086, and P9604 provided
from June 1, 2019, to August 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ConfirmMDx for Prostate Cancer Epigenic Molecular Assay testing provided on June 16, 2020.You asked the Plan to pay forthe ConfirmMDx for Prostate Cancer Epigenic Molecular Assay testing. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says the services rendered were not medically necessary.The Plan follows Medicare rules. Medicare rules say that ConfirmMDxtesting is only covered for certain indications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the ConfirmMDx for Prostate Cancer Epigenic Molecular Assay testing. Our reviewer says that the documentation does not support that the requested Our physician reviewer found the enrollee had an elevated prostate specific antigen (PSA). The documentation does not support that the enrollee in this case is being considered for a repeat biopsy due to persistent or elevated cancer-riskfactors. Therefore, the enrollee did not meet criteria for the rendered 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 the ConfirmMDx for Prostate Cancer Epigenic Molecular Assay testing have not been met. Therefore, we decided that the Plan does not have to pay forthe ConfirmMDx for Prostate Cancer Epigenic Molecular Assay testing provided on June 16, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe psychotherapy services provided on April 20, 2020 by an out of network provider.You asked the Plan to pay forthe psychotherapy services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request prior authorization.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 has network providers available who can provide the services at issue in this appeal. 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 forthe psychotherapy services provided on April 20, 2020 by an out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 81455) provided on June 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that LCA A56199 provides a list of CPT codes for which genetic testing procedures are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. We looked at the file and Medicare rules. Per A56199, CPT code 81455 is considered not medically necessary, and therefore is non-covered. 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 pay for the services (CPT 81455) provided on June 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKeytruda (CPT Code J9271).You asked the Plan to pre-approvethe medication. You say that the medication is necessary.The Plandenied your request. The Plan says the medication is not necessary.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 medication. Our physician reviewer found yes, therequested use of Keytruda FDA-approved for the enrollee's diagnosis. It is for the treatment of recurrent or metastatic cervical cancer in patients whose tumors express PD-L1 (CPS =1), as determined by an approved test, and with disease progression on or after chemotherapy. No PD-L1 status is reported on this patient. Does the documentation support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee? Need PD-L1 status to determine.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 medication have not been met.Therefore, we decided that the Plan does not have to pre-approveKeytruda (CPT Code J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient therapy services provided from May 11, 2020, to May 21, 2020.You asked the Plan to pay foroutpatient therapy services. You say that the Plan should pay these claims.The Plan denied your request. The Plan says the services are not supported in the records.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.We looked at the file and Medicare rules. The medical records submitted are not for the claim dates of service. Based on this information, we decided that Medicare rules for coverage of outpatient therapy services have not been met.Therefore, we decided that the Plan does not have to pay foroutpatient therapy services provided from May 11, 2020, to May 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 20, 2019, through December 18, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted medical records contain discrepancies with the reported place of service noted on the submitted claim form and the documentation does not include a signed physician order or signed laboratory requisition for the billed test.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. The rules also say that the physician must clearly document, in the medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the record indicates that the specimen was collected in an outpatient setting. Additionally, the record does not include a physician order or records explicitly requesting the test rendered. Therefore, we decided that the Plan does not have to pay for laboratory services provided on September 20, 2019, through December 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinuation of SNF care provided from December 11, 2020, forward.You asked the Plan to pre-approveSNF 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 above 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 have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the daily skilled services can be provided at a lower level of care than a skilled nursing facility. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can receive services at a lower level of care. Admission to a SNF for inpatientskilled rehab services is not 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinuation of SNF care provided from December 11, 2020, forward.
Appeal type: Lab
Decision: Favorable

We decided that the Planhasto pay forthe lab testing provided on May 11, 2020.You asked the Planto pay forthe lab testing. You say that this should be paid.The Plandenied your request. The Plansaysthatthis was coded incorrectly and a new claim must be submitted.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 provide any specific rationale to support the claim that this was incorrectly coded. Maximus finds no apparent errors on the face of this claim, and without a specific issue noted by the Plan, we find that this denial of payment is not substantiated.Therefore, we decided that the Planhas to pay forthe lab testing provided on May 11, 2020.If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe telehealth office visit (99214) provided on July 23, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe telehealth visit. You say that this doctor has been treating you for sleep apnea for over 10 years. The plan has paid partial of your bills in the past for his services, therefore you're confused as to why not now.The Plan denied your request. The Plan says this service is not covered when rendered out of network.The Plan must follow Medicare rules. Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare. As a member of the PPO plan you can receive your care from either a network provider or an out-of-network provider. The requested provider in this case is not a network provider with the Plan. The health plan contract on page 104 specifically says that virtual care is not covered out of network. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plandoes not have to pay forthe telehealth office visit (99214) provided on July 23, 2020, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient mental health stay provided from July 17, 2020, to August 3, 2020.You asked the Plan to waive the copayment foran inpatient mental health stay. You say that you cannot afford the charges and are homeless due to the hospital stays.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 $390 copayment for days 1-5 for inpatient mental health care. You have been asked to pay $1,560, which is less than the total copayment amount,for an inpatient mental health stay. An inpatient mental health stay falls within the inpatient mental health care benefit category. This means thatyou 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 foran inpatient mental health stay provided from July 17, 2020, to August 3, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reduce the copayment for the injection of drug into eye (67028) provided on July 22, 2020.

You asked the Plan to reduce the copayment for the injection of drug into eye. You say that the copayment was incorrectly calculated. The Plan denied your request. The Plan says that the copayment applied correctly in this case.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $10 copayment for vision care. 

The Plan says you must pay a $50 copayment for the injection of drug into eye. Based on the Plan contract, however, you cannot be asked to pay more than a $10 copayment for the injection of drug into eye. Therefore, we decided that the Plan has to reduce the copayment for the injection of drug into eye (67028) provided on July 22, 2020. 

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider on June 25, 2020.You asked the Plan to waive the copayment for an x-ray. You say that you do not agree with these charges. 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 $130 copayment for outpatient diagnostic tests/radiological diagnostic services. You have been asked to pay a $130 copayment for an x-ray. An x-ray falls within the outpatient diagnostic tests/radiological diagnostic services 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 an x-ray provided by a participating provider on June 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical services (CPT 15002, 15003, 15004) provided to the enrollee on April 7, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the denied codes remain 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 the denied codes is:CPT 15002:Surgical preparation or creation of recipient site by excision of openwounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and childrenCPT 15003:Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure)CPT 15004:Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids,mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children.

We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation submitted was reviewed anddoes not meet the criteria. The operative report does not include documentation that CPT 15002, CPT 15003 and CPT 15004 is a separate procedure. The services documented should be reported with skin graft/replacement codes.We looked at this coder'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 pay forsurgical services (CPT 15002, 15003, 15004) provided to the enrollee onApril 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from
June 17, 2020, through June 20, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service 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 $295
copayment per day, for days 1-6 and a $0 copayment per day, for days 7-90 for inpatient hospital care.
You have been asked to pay $885 ($295 copayment x 3 days) for the inpatient hospital care provided. This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for the inpatient hospital care provided from June 17, 2020,
through June 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe liquid oxygen contents provided from June 12, 2020, to July 17, 2020 billed with multiple units of E0442.You asked the Plan to pay forthe liquid oxygen contents as billed. You say that you feel that this should be denied in the same manner that it would be in Original Medicare so that you canbill the secondary insurance.The Plan denied your request. The Plan says this was correctly denied as the number of units of this code exceed what is allowable based on the code definition.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 E0442 is Stationary oxygen contents, liquid, 1 month's supply = 1 unit.We find that the multiple units of CPT code E0442 are not supported in the medical record. Specifically, the definition of the code would not allow for multiple units to be billed within a one-month period as each unit represents a one-month supply. Based on this information,we decided that Medicare rules for coverage of the liquid oxygen contents as billed have not been met.Therefore, we decided that the Plan does not have to pay forthe liquid oxygen contents provided from June 12, 2020, to July 17, 2020 billed with multiple units of E0442