Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), cleaning (D1110), intraoral x-rays (D0220, D0230), and bitewing x-rays (D0274) provided on December 3, 2020.
You asked the Plan to pay for the dental services. You say that these services were necessary and should be covered. The Plan denied your request. The Plan says only one intraoral periapical x-ray can be covered per calendar year. You had two x-rays, but only one can be covered. In addition, the provider in question is not part of the Plan's network. Out-of-network dental services require 50% coinsurance. The coinsurance for the first intraoral x-ray, bitewing x-rays, cleaning, and evaluation was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% coinsurance for dental services provided out-of-network. 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.
You have been asked to pay 50% coinsurance for the covered dental services that were provided out-of-network. 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the second intraoral x-ray exceeds the number covered in a calendar year. The Plan will cover one intraoral x-ray procedure per year. You received 2 intraoral x-ray images, so the first is covered with the applicable coinsurance and the second should remain denied. Therefore, we decided that the Plan does not have to pay an additional amount or waive the coinsurance for the periodic oral evaluation (D0120), cleaning (D1110), intraoral x-rays (D0220, D0230), and bitewing x-rays (D0274) provided on December 3, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a cardiac catheterization and angiogram at an out-of-network tertiary facility (93565, 93454, 92978, 93453).
You asked the Plan to pre-approve the cardiac catheterization and angiogram at an out-of-network tertiary facility. You say that you received your heart transplant at the facility and you are followed by the out-of-network provider. The out-of-network tertiary facility offers expertise the plan does not have. The Plan denied your request. The Plan says that there is a network cardiologist that can provide the angiogram in the community setting.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 cardiac catheterization and angiogram at an out-of-network tertiary facility. Our reviewer says that the requested cardiac catheterization and angiogram at an out-of-network tertiary facility is medically necessary.
Our physician reviewer found that comparison to prior studies, especially the prior coronary ultrasound results (necessary for coronary surveillance in post-transplant patients) is important to assess the progression of any prior known coronary artery disease. The tertiary facility offers continuity of care and comparison to multiple available prior studies, and expertise with the management of post-transplant coronary artery disease (which is pathologically different from routine atherosclerotic disease) that the network provider cannot offer. Given the specialized nature of her disease, obtaining these services at the tertiary facility that performed the transplant and has been following her for rejection since that time is medically necessary for this patient. 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 cardiac catheterization and angiogram at an out-of-network tertiary facility have been met. Therefore, we decided that the Plan has to pre-approve a cardiac catheterization and angiogram at an out-of-network tertiary facility (93565, 93454, 92978, 93453).
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to LTACH.
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 was admitted due to hypoxic respiratory failure from COVID pneumonia. The enrollee is hypotensive. The enrollee continues to receive acute care services that have not been denied. The medical records provided do not indicate that the enrollee requires acute care services that she is not currently receiving that would be available at the LTACH. The elements of the coverage rules are not satisfied.
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-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBotox under the enrollee's Medicare Part B benefit.You asked the Plan topre-approveBotox under Medicare Part B. You say that this drug is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met as its not being taken from physician stock. Maximus overturned the Plans denial stating the drug was shown to be medically necessary. The Plan requested a reopen and stated the issue was not medical necessity but the fact that the injection was not being taken from physician stock and therefore was not covered under the Medicare Part B benefit.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, it has been confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage.Therefore, we decided that the Plan does not have to pre-approveBotox under the enrollee's Medicare Part B benefit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe gauze provided on January 14, 2021.You asked the Plan to pay forthe gauze. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are included in the payment of another code.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 A6219 is gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing.We find that CPT code A6219 is not supported in the medical record. Specifically, this code is considered as part of the global surgical package of the initial procedure 11043 (Debridement, muscle and/or fascia(includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less) billed on the same claim. The medical records show and indicate that the service was related the debridement procedure that was performed on the same date of service. Based on this information, we decided that Medicare rules for coverage of the gauze have not been met.Therefore, we decided that the Plan does not have to pay forthe gauze provided on January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on October 23, 2020.
You asked the Plan to pay for a pneumatic compression device. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for pneumatic compression devices have not been met.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on October 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on May 28, 2020.
You asked the Plan to pay for therapeutic exercises. You say that this should be covered. The Plan denied your request. The Plan says there is a more appropriate code for the service provided.
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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
We find that CPT code 97110 is not supported in the medical record. Specifically, the record shows that the service at issue was provided by a therapist assistant in the home health or hospice setting. There is a more appropriate code for this service. Based on this information, we decided that Medicare rules for coverage of therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on May 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

Wedecided that the Plan does not have to pay forthe home health services provided to the enrollee on August 24, 2020.You asked the Plan to pay forhome health services. You say that the codes on the claim are valid and correct.The Plandenied your request. The Plan says this was not billed with a required location code.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, this claim was not billed with a Q code to report where home health services were provided. Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee on August 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) provided on January 8, 2021.
You asked the Plan to pay for a PET scan. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with an appropriate diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate diagnosis code.
We looked at the file and Medicare rules. The billed diagnosis code, C34.90, is not listed as an appropriate code. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) provided on January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 150.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract says that providers are paid based on Maximum Allowable Charge (MAC). For services covered under the plan, you may still be billed by an out of network provider for any amount greater than the MAC payment made by the plan to the provider. You can find this information on page 4-71 of the Plan's 2020 Evidence of Coverage (EOC). 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 and the services are listed as covered, dental services performed out of network may have a higher cost share amount. The Evidence of Coverage clearly states that you may still be billed by an out of network provider for any amount greater than the MAC payment made by the plan to the provider. Therefore, we decided that the Plan does not have to waive the member liability forthe limited oral evaluation (D0140) and the extraction (D7210) provided on November 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on November 17, 2020.
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says there is no coverage if hearing aids or related services are received from an out-of-network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan's hearing aid provider. We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on November 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the prophylaxis (D1110) received January 8, 2021 from the out-of-network provider.
You asked the Plan to pay an additional amount for the prophylaxis. You say that the Plan should pay more for the cleaning. The Plan denied your request. The Plan says you may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the 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 requested payment is in excess of that which is covered under this benefit. The Plan agreed to pay up to 100% of the in-network fee schedule
(INFS). You are responsible for the difference between the INFS and the out-of-network provider's charged fees. Therefore, we decided that the Plan does not have to pay an additional amount for the prophylaxis (D1110) received January 8, 2021 from the out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on November 7, 2020.
You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided 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. Cardiovascular risk assessment panels are only covered for certain indications. Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129, and L36523 to support their denial. However, LCD L36139, L36129, and L36523 are not valid for the provider's billing state of Pennsylvania. Therefore, we are unable to use LCD L36139, L36129, and L36523 to substantiate our decision. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on November 7, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the bronchoscopy services coded 31624 provided on November 17, 2020.
You asked the Plan to pay for the bronchoscopy 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 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. In this case, the CPT Code Manual definition of code 31624 is bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage.
We find that CPT code 31624 is not supported in the medical record. Specifically, the medical records submitted did not include that bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage was performed. Based on this information, we decided that Medicare rules for coverage of the bronchoscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the bronchoscopy services coded 31624 provided on November 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve home health aide services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 home health aide services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. As you are not receiving skilled nursing or skilled therapy the criteria of home health aide services per Section 50.2 is not met and the
request for home health aide services is not reasonable and necessary to the treatment of your illness or injury by the skilled professional staff. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forspecialist services provided on October 26, 2020, and January 12, 2021.You asked the Plan to waive the copayments forspecialist services. You say that you received a failed lumbar puncture and non-billable services and should not be responsible for the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialist services.You received specialist services on October 26, 2020, and January 12, 2021. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $80.  You have been asked to pay the total copayment amount of $80 for specialist services. Specialist services fall within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forspecialist services provided on October 26, 2020, and January 12, 2021.