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

We decided that the Plan does not have to pre-approve Synvisc-One.
You asked the Plan to pre-approve Synvisc-One. You say that the requested Synvisc-One is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Monovisc and Orthovisc first.
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 Synvisc-One. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found based on the medical records provided the enrollee has not tried and failed the required drug(s). There is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9500 provided from March 6, 2020 to March 11, 2020.

You asked the Plan to pay for the home infusion therapy 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 payable.

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 S9500 is home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 

We find that CPT code S9500 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9500 provided from March 6, 2020 to March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 25, 2019.
You asked the Plan to pay for the services. 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 for the services provided by an out-of-network provider on August 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care services rendered on July 25, 2020.
You asked the Plan to waive the copayment for these services. You say that the copayment should be $0. The Plan denied your request. The Plan says the copayment 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 a $30 copayment for each visit in a contracted urgent care center or walk-in clinic.
Review of the file shows that you received urgent care services on July 25, 2020. You have been asked to pay a $30 copayment for these services. These services fall within the visit in a contracted urgent care center or walk-in clinic 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 the urgent care services rendered on July 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth x-ray (D0210) provided on December 21, 2020.
You asked the Plan to pay for the dental service. You say that this service should be covered. You say that you were advised by a plan representative that the provider was in network. You say that you were overcharged for the x-ray. You say that the previous provider committed malpractice by failing to diagnose 2 significant problems. You say that it is reasonable for someone to seek a second opinion. You also say that it was essential to your diagnosis. The Plan denied your request. The Plan says 1 full mouth or panoramic x-ray are covered per calendar year. The Plan also says that the frequency limit has been exceeded.
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 full mouth x-ray is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a full mouth x-ray that you received on August 20, 2020. Therefore, we decided that the Plan does not have to pay for the full mouth x-ray (D0210) provided on December 21, 2020.
Your complaints about the previous provider that you saw are not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan denied your request. The Plan says that the enrollee must try and fail an oral bisphosphonate drug and zoledronic acid.
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 Prolia. Our reviewer says that the requested Prolia is medically necessary. Our physician reviewer found in this case, the enrollee has age related osteoporosis and has had a compression fracture. The enrollee has tried and had an adverse effect to risendronate. The literature (e.g. Ther Adv Musculoskelet Dis. 2011 Feb; 3(1): 31-41) that there may be cross-reactivity with intravenous bisphosphonates. The prescriber has indicated a sufficient medical rationale why zoledronic acid is not appropriate for the enrollee. The elements of the coverage rule are satisfied. The requested service is recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pre-approve Prolia.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on February 11, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you would like to appeal these services. The Plan denied your request. The Plan says the maximum allowed for oral exams had 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. Though the Plan offers a dental benefit in excess of Medicare coverage, oral exams are limited to 1 every 6 months. The record shows that you received a comprehensive oral evaluation on December 3, 2020, and your oral exams benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on February 11, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the emergency ambulance transportation (A0425, A0429) received September 25, 2020.
You asked the Plan to pay for the ambulance transportation. You say that you were in severe pain and required emergency transportation. The Plan denied your request. The Plan says that based on your condition, medical necessity for this level of care was not established.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We looked at the file, and Medicare rules. The enrollee's level of pain reported on this date of service (10/10 and later 8/10) meets the prudent layperson's definition of an emergency. Without immediate medical attention, a prudent layperson would have reasonably believed that there would be serious jeopardy to the enrollee's health for this level of pain and a worsening condition. Based on this information, we decided that Medicare rules for coverage of the emergency ambulance transportation have been met. Therefore, we decided that the Plan has to pay for the emergency ambulance transportation (A0425, A0429) received September 25, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical and imaging services rendered on July 24, 2020.

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 services are not covered.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 

In this case, the MUE for CPT code 37238 (transcatheter placement of intravascular stent[s]) is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these services have not been met.

The file shows that billed procedure code 75822 (venography) was previously paid by the Plan on a separate claim for the same date of service. 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 surgical and imaging services rendered on July 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the correction of a bunion provided on
October 15, 2020.
You asked the Plan to waive the coinsurance for the correction of a bunion. You say that you 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 outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You received the correction of a bunion of October 15, 2020, at an outpatient hospital facility. The correction
of a bunion is considered an outpatient surgical procedure. Therefore, you are responsible to pay your share of
the cost-sharing charges. The total allowed amount is $3,561.08 and 20% of that is $712.22.
You have been asked to pay the total coinsurance amount of $712.22 for the correction of a bunion. The
correction of a bunion falls within the outpatient surgery, including services provided at hospital outpatient
facilities and ambulatory surgical centers 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
for the correction of a bunion provided on October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 28, 2020.
You asked the Plan to pay for the services. 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 for the services provided by an out-of-network provider on August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on December 28, 2020.

You asked the Plan to pay for the moderate sedation 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 payable.

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 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service).

We find that CPT code 99153 is not supported in the medical record. Specifically, this code has a Professional Component (PC)/Technical Component (TC) indicator of 3 per the National Physician Fee Schedule. CPT code 99153 may not be paid if furnished to a hospital inpatients or patients in a hospital outpatient department. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on December 28, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care supplies provided on August 27, 2020.
You asked the Plan to pay for the wound care supplies. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 18, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for wound care supplies provided on August 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) received December 4, 2020.

You asked the Plan to pay for the prophylaxis. You say that you need three teeth cleanings per year. The Plan denied your request. The Plan says your benefit is limited to two teeth cleanings per calendar year.

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 up to two prophylaxis visits per calendar year. 

We looked at the file, and Medicare rules. Your benefit allows up to two prophylaxis per calendar year. You exhausted this benefit prior to the date of service in dispute. Based on this information, we decided that the Plan's rules for coverage of the prophylaxis have not been met. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) received December 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy services rendered on December 23, 2020.

You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the coinsurance 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 20% of the total cost for Medicare-covered Part B chemotherapy drugs.

Review of the file shows that you received chemotherapy services on December 23, 2020. You have been asked to pay 20% of the total cost for these services. These services fall within the Medicare-covered Part B chemotherapy 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 for the chemotherapy services rendered on December 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided to the enrollee on December 9, 2020.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says the submitted documentation indicates the enrollee was medically stable at the time of transportation.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found there is no indication of medical instability or need for vital monitoring during transport. Per the medical records provided, they do not support the medical necessity of ambulance services for transport from the hospital to the rehab facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services provided to the enrollee on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received from September 25, 2020, to November 24,2020.
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services you received from September 25, 2020, to November 24,2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Freestyle Libre2 continuous glucose monitor (CGM).
You asked the Plan to pre-approve a Freestyle Libre2. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested device is not medically necessary.
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. Medicare rules say that therapeutic CGMs are considered reasonable and necessary for enrollees with diabetes who meet criteria referenced above. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that the case file submitted to Maximus was largely incomplete. The case file is missing the Notice of Denial of Medical Coverage for the item or any other letter provided to you, the enrollee to show that this item is non-covered.
The Plan states that the requested item is not medically necessary, however does not show exactly why you do not meet the criteria for the requested device. The documentation submitted by the Plan supports that you meet criteria for the requested CGM as you have diabetes, check your blood glucose levels four times daily, are insulin-treated with multiple (three or more) daily injections, and require frequent adjustment on the basis of the testing reults. In addition, it appears that you already have a CGM and is requesting continuation of the device. Therefore, we decided that the Plan has to pre-approve a Freestyle Libre2 continuous glucose monitor (CGM).