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

We decided that the Plan does not have to pay for the Prostate Gene Expression Profile testing rendered to the enrollee on November 11, 2018.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing was 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 pay for these services. Our reviewer says that the testing was not medically necessary. Our physician reviewer found the enrollee had abnormal tumor markers and received a Prostate Gene Expression Profile. This testing is considered investigational in nature and was therefore not reasonable or medically necessary for the enrollee. 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 pay for the Prostate Gene Expression Profile testing rendered to the enrollee on November 11, 2018.
The Plan references Local Coverage Determination (LCD) L36807 in their determination; however, this LCD is not binding for Part B Medicare and was not used in the MAXIMUS determination.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an out-of-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 has network providers available who can provide 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 office visit provided on August 14, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for spinal fusion surgery (22558) provided on June 24, 2019.
You asked the Plan to pay for the spinal fusion surgery. You say that while other providers would not treat the member, this provider had the confidence and equipment to successfully perform the surgery. The Plan denied your request. The Plan says reimbursement is not issued for services provided by an opt-out provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the physician. This provider has opted out of the Medicare program. The file shows that the physician entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for spinal fusion surgery (22558) provided on June 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from September 24, 2019 to October 17, 2019.
You asked the Plan to pay for chiropractic services. You say that you went to a different provider and they were not able to help with your issues, and this provider told you they have been paid by the Plan in the past. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for chiropractic services provided from September 24, 2019 to October 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory testing provided on February 19, 2019.You asked the Plan to pay forthe laboratory testing. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says the services rendered are not a covered benefit.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 laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory testing provided on February 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that SI joint injections are covered when specific criteria are met. 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 enrollee has chronic low back pain and has received multiple interventions, including diagnostic SI joint injections and sacral lateral branch injections. The degree of pain relief for these injections is not documented and there are no documented changes in mobility. Given that there is no documentation of the degree of effectiveness of the prior interventions, the requested therapeutic 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 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transportation services from an out-of-network provider.You asked the Plan to pre-approvethe out-of-network transportation services. You say that you need the requested transportation services in order to get to and from dialysis.The Plan denied your request.The Plan says the provider is an out-of-network provider. The Plan says that there are multiple in-network providers who are available for your care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a networkprovider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvetransportation services from an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Valacyclovir HCL tablet for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is a drug that is taken orally.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Valacyclovir HCL tablet for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on May 17, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
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 the services was not filed until August 29, 2019. 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 services provided to the enrollee on May 17, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve a semi-electric hospital bed for the enrollee.You asked the Planto pre-approvethe bed. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no need for frequent changes in body position that the enrollee cannot do herself.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.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 bed. Our reviewer says that the requested bed is not medically reasonable or necessary. Our physician reviewer found the records do not indicate the enrolleewarrants frequent or immediate changes in body position, and/or special attachments that cannot be fixed on an ordinary bed. 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 bed have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea semi-electric hospital bed for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre sensors (continuous glucose monitor).
You asked the Plan to pre-approve the sensors. You say that this is medically necessary. The Plan denied your request. The Plan says medical necessity cannot be established, as you are not currently on insulin.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 sensors. Our reviewer says that the requested sensors is not medically reasonable or necessary. Our physician reviewer found the enrollee has diabetes. He does not use insulin to manage his diabetes. No recent A1C, blood sugar log or documentation of management of diabetes is included. The documentation does not show that the CGM will be used in place of a blood glucose monitor for the enrollee for making diabetes treatment decisions (for example, changes in diet and insulin dosage). The request 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 sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre sensors (continuous glucose monitor).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from November 24, 2018 to November 30, 2018.You asked the Plan to pay for the inpatient admission. You say that your facility is prohibited by Federal law to bill Medicare. You say that medical claims for military hospitals represent indebtedness by the third party payer to the United States. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. The Plan must follow Medicare rules. Medicare rules say that payment may not be made for items and services furnished by a provider of service or agency ofthe Federal government. Federal providers are excluded from participation in the Medicare program.We looked at the file and Medicare rules. Medicare saysthat payment may not be made for items and services furnished by a provider of service or agency of the Federal government. Federal providers are excluded from participation in the Medicare program.Based on this information, we decided that Medicare rules for coverage of the inpatient admission have not been met. Therefore, we decided that the Plan does not have to pay foran inpatient admission provided from November 24, 2018 to November 30, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit, electrocardiogram, and laboratory services (99213, 99397, 93010, 81003, and 82272) provided from April 23, 2019 to August 1, 2019.
You asked the Plan to pay for an office visit, electrocardiogram, and laboratory services. You say that you have previously been reimbursed for services from this provider. The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the physician. This provider has opted out of the Medicare program. The file shows that the physician entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for an office visit, electrocardiogram, and laboratory services (99213, 99397, 93010, 81003, and 82272) provided from April 23, 2019 to August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on September 3, 2019.You asked the Plan to waive the coinsurance forMedicare Part B drugs. You say that you were not told that you would owe coinsurance and 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 20% coinsurance for Medicare Part B prescription drugs.You received Medicare Part B drugs on September 3, 2019. The total allowed amount is $2,277.80 and 20% of that is $455.56.  You have been asked to pay the total coinsurance amount of $455.56 for Medicare Part B drugs. Medicare Part B drugs fallwithin the Medicare Part B prescription drugs 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 coinsurance forMedicare Part B drugs provided on September 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cancer screening provided on August 15, 2019.You asked the Plan to pay for the cancer screening. The Plan denied your request. The Plan says the hereditary screenings are not covered by Medicare.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 tests at issue in this appeal (CPT Codes 81406 and 81479) were requested for screening purposes. There were insufficient records provided to show the results of this testing would be used to determine a specific diagnosis or determine a specific treatment strategy for disease or illness present in the enrollee at the time of service. Medicare does not cover these tests for screening purposes. Therefore, we decided that the Plan does not have to pay forthe hereditary cancer screening provided on August 15, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ECG provided on March 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an ECG. You say that these tests were ordered based on the best interest of the patient. The Plan denied your request. The Plan says no prior authorization was obtained for this service.
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 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 an ECG provided on March 4, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from June 20, 2019 to July 1, 2019.You asked the Plan to payforhome health services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are missing required information.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically,the claim does not have the appropriate home health data to process and pay the claim. The FIPS Value Amount needs to be 5 digits then .00 -the 5 digits are actually a ZIP Code. The provider submitted 607300 which is 6 digits.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from June 20, 2019 to July 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on June 6, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were not seen by the provider. You say you were turned away and told to go to your primary care physician and you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $65 copayment for each Medicare-covered urgent care visit received at an urgent care facility. You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The medical record shows you were seen for a wound follow-up at the urgent care center.
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 urgent care visit provided on June 6, 2019.
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 services are necessary.The Plan denied your request. The Plan says the enrollee can receive the care required at the current facility they are in. Therefore, coverage criteria has not been met.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 currently undergoing treatment at an acute care hospital (ACH) for acute-on-chronic respiratory disease. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferringthe enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on September 17, 2019.You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says the services rendered are not a covered benefit.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 laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory testing provided on September 17, 2019.