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

We decided that the Plan does not have to pre-approvethe heart valve procedure (CPT Code(s): 33418, 33419, 93355).You asked the Plan to pre-approvethe procedure. You say that the procedure is necessary.The Plan denied your request. The Plan says the records do not show that the enrollee has been evaluated by a heart surgeon.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 procedure. Our physician reviewer found the most recent clinic note January 25, 2021, does not document any symptoms or objective findings of congestive heart failure and the recent cardiac catheterization likewise does not document significant elevation in left heart diastolic pressures or PA pressure. Therefore, the records do support the medical necessity for a MitraClip procedure. In addition, the documentation doesnot indicate the enrollee has been evaluated by a heart surgeon.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 procedure have not been met.Therefore, we decided that the Plan does not have to pre-approvethe heart valve procedure (CPT Code(s): 33418, 33419, 93355).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services (A0425NP, A0425PN, A0428NP, and A0428PN) provided on July 9, 2020.You asked the Plan to pay forthe ambulance services. You say that the ambulance transportation was medically necessary.The Plan denied your request. The Plan says ambulance transport to or from an outpatient office is not a Medicare covered benefit.The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.Therefore, we decided that the Plan does not have to pay forthe ambulance services (A0425NP, A0425PN, A0428NP, and A0428PN) provided on July 9, 2020
Appeal type: Inpatient Hospital
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 April 11, 2020, to April 13, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not covered for the listed diagnosis code.
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 medical services provided to the enrollee by an out-of-network provider on April 11, 2020, to April 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forintegrated biopsychosocial assessment (90791) provided February 21, 2019.You asked the Plan to pay forthe assessment. You say that please see attached reconsideration letter and process for payment.The Plan denied your request. The Plan says the time limit for filing has expired.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 assessment was not filed until 08/26/2020. 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 forintegrated biopsychosocial assessment (90791) provided February 21, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lead wires provided on September 18, 2020.You asked the Plan to pay forthe lead wires. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the items rendered are not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that replacement lead wires are only covered once every twelvemonths.We looked at the file and Medicare rules. The enrollee received lead wires prior to twelvemonths before the date of service of September 18, 2020. Based on this information, we decided that Medicare rules for coverage of the lead wires have not been met. Therefore, we decided that the Plan does not have to pay forthe lead wires provided on September 18, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) and complete series of intraoral x-rays (D0210) provided on August 11, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe periodic oral evaluation and complete series of intraoral x-rays. You say that this claim should be reprocessed and approved for payment.The Plan denied your request. The Plan says the member is responsible for 100% of the cost for dental services rendered by an OON provider.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the periodic oral evaluation and complete series of intraoral x-rays when the services are rendered by an in-network provider. 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.Based on this information, we decided that the Plan's rules for coverage of the periodic oral evaluation and complete series of intraoral x-rays have not been met.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) and complete series of intraoral x-rays (D0210) provided on August 11, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe panoramic x-ray provided on October29, 2020.You asked the Plan to pay forthe panoramic x-ray. You say that you needed to receive a different x-ray because the technician was unable to get the standard film device into your mouth.The Plan denied your request. The Plan says this service is not covered under your plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The only x-rays that are covered under your plan are periapical x-rays.Therefore, we decided that the Plan does not have to pay forthe panoramic x-ray provided on October 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe catheter removal procedure provided on December 13, 2019.You asked the Plan to waive thecopayment forthe catheter removal procedure. You say that you were told you would not be charged. You say the took the PICC out and that was it. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.Therules 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 $325 copayment for outpatient hospital facility. You have been asked to pay a $325 copayment for the catheter removal procedure. The catheter removal procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the catheter removal is considered a surgical procedure.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 forthe catheter removal procedure provided on December 13, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on September 10, 2020.You asked the Plan to pay forthe services. You say that you were not told that the provider is out-of-network.The Plan denied your request. The Plan says the services were not authorized.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 forthe medical services provided to you by an out-of-network provider on September 10, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe after cataract laser surgery provided on August 19, 2020.You asked the Plan to waive the copayment forthe after cataract laser surgery. You say that you do not understand why this procedure is being billed as a surgery. You say you were not putunder anesthesia. 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 $275 copayment for freestanding ambulatory surgical center. You have been asked to pay a $275 copayment for the after cataract laser surgery. The after cataract laser surgery falls within the "Outpatient hospital services" benefit category. The record shows the after cataract laser surgery is considered a surgical procedure. The record also shows that a local anesthetic was applied to the left eye. 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 forthe after cataract laser surgery provided on August 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe image guided radiation therapy (IGRT).You asked the Plan to pre-approvethe IGRT. You say that IGRT is medically necessary.The Plan denied your request. The Plan says IGRT is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the IGRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the physician rationale for IGRT in the clinical records is: "basic minimum imaging for this treatment" without any other supporting rationale. While IGRT for whole breast radiation is an accepted standard for exceptional circumstances, in this specific case the routine use of IGRT is not within accepted standards or care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the IGRT have not been met.Therefore, we decided that the Plan does not have to pre-approvethe image guided radiation therapy (IGRT)
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan does not have to pay forthe chest x-ray (71045) provided on April 17, 2020.You asked the Plan to pay forthis claim. You say that this service should be paid by the Plan.The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopenand provided additional information. The Plan states this claim deniedbecause the Plan had alreadypaid for this service under another claim. The Plan states the medical recordsdo not support why this procedure had been rendered twice on the same day. The NPI website shows that both providers practice as Diagnostic Radiology Specialistsand belong tothe same practice.  The case file also includes the claim image for the appealed and referring claims that show that both providers belong to the same physician group. For payment consideration, the correct billing of this service needed to include modifier 59,which is used to distinguish separate and distinct service. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when necessary the appropriate modifiers. In this case the claim under appeal cannot be paid due to the omission of a modifier to show this was a separate and distinct service from those provided previously by a provider in the same group. Medicare rules for coverage of this claim as billed have not been met.Therefore, we decided that the Plan does not have to pay forthe chest x-ray (71045) provided on April 17, 2020under the above-mentionedclaim.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay forimaging interpretation services provided to the enrollee on April 24, 2020 and billed under code 73564-26-LT.You asked the Plan to pay this claim as billed. You say that these interpretation servicesshould be covered by the Plan.The Plandenied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that this claim denied because the provider billed with an invalid diagnosis code. The Plan states that the provider billed with the LT modifier, but  the diagnosiscode billed was S810.19A or "Laceration without foreign body, unspecified knee, initial encounter."The case medical records show this service was performed on the left knee. Therefore, the provider should have billed with diagnosis code as S81. 012A for "Laceration without foreign body, left knee, initial encounter for payment consideration".The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providersmust report services correctly. Providers must report services with the appropriate codes. When a service is performed on a specified part of the body, such as right knee or left knee, the correct diagnosis code must be used. In the original decision, Maximus stated that although the x-ray was done on the left knee, there isno indication in the available record specifying which side the knee laceration is on.However, both the records provided by the Plan and the "LT" modifier indicated on the claim suggest the service was performed on the left knee, therefore, the appropriate diagnosis code to indicate service to the left knee would be required. Medicare rules for coverage of this claim have not been met.Therefore, we decided that the Plan does not haveto pay forimaging interpretation services provided to the enrollee on April 24, 2020 and billed under code 73564-26-LT.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan does not have to waivethe $10 charge for having your eyeglasses polished.You asked the Plan to waivethis cost share. You say that this service should be covered by the Plan.The Plan denied your request. The Plan says eyeglasses polishing is not covered under the supplemental vision benefit. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.The Plan is correct in this case. Medicare does not cover eyeglasses or services related to eyeglasses whether the provider is in network or out of network. The Plan contract covers vision services as a supplemental benefit, which they are not required to do by Medicare. Eyeglasses polishing is not a covered vision benefit under your Plan contract. Medicare does not make exceptions to supplemental benefits. Therefore, we decided that the Plan does not have to waivethe $10 charge for having your eyeglasses polished.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve(CPT Code L5981), (L5968) and (L5962).You asked the Plan to pre-approvethe items. You say that the services are necessary.The Plan denied your request. The Plan says the records do not show why the requested advanced foot and extra cover are needed.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 items. Our physician reviewer found L5981, L5968, andL5962,are not medically necessary. The treating medical practitioner progress notes do not support that this patient is a K3 ambulator or requires flexible protective outer surface covering system (L5962) with needs for protection against unusually hard environmental situations. 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 items have not been met.Therefore, we decided that the Plan does not have to pre-approve(CPT Code L5981), (L5968) and (L5962)
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Hyalgan injection (J7321).You asked the Plan to pre-approveHyalgan. You say that this drug is medically necessary.The Plan denied your request. The Plan says step-therapy criteria was not met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Hyalgan. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found There is no evidence that the enrollee is allergic to or intolerant of these other forms of hyaluronic acid as required by the Plan. There is no evidence that the enrollee has tried and not responded to these other forms of hyaluronic acid injections. There is no documentation as to why these other forms of hyaluronic acid would not be expected to be safe and effective 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 Hyalgan have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Hyalgan injection (J7321).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for14 dental extractions (D7140 x 14) performed.

You asked the Plan to pay for 14 dental extractions. You say that the provided services were pre-approved by the Plan.The Plan denied your request. The Plan says rules for payment have not been met.

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. 

In this case, the enrollee received 16 dental extractions. The Plan has agreed to pay for 2 dental extractions. The Plan covers 2 dental extractions per calendar year. Based on this information, we decided that the Plan's rules for coverage of the remaining 14 dental extractions have not been met.Therefore, we decidedthat the Plan does not have to pay for14 dental extractions (D7140 x 14  performed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foranesthesia services provided on August 26, 2020 by an out of network (OON) provider.You asked the Plan to pay foranesthesia services. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.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 foranesthesia services provided on August 26, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Superion interspinous spacer for the enrollee.You asked the Plan to pre-approvethese services. You say that these services are medically necessary.The Plan denied your request. The Plan says that this service is 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The spacer device is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea Superion interspinous spacer for the enrollee.