Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide sensors for use with an interstitial continuous glucose monitor (A9276).

You asked the Plan to provide sensors for use with an interstitial continuous glucose monitor (CGM) (A9276). You say that the sensor will be effective for you. The Plan denied your request. The Plan says since the CGM is not one of the approved continuous glucose monitors the supplies for it are not approved either.

The Plan must follow Medicare rules. Medicare rules say that this code is not used to bill for supplies used with a covered therapeutic continuous glucose monitor.

We find that CPT code A9276 is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of sensors for a continuous glucose monitoring system have not been met. Therefore, we decided that the Plan does not have to provide sensors for an interstitial continuous glucose monitoring system. Therefore, we decided that the Plan does not have to provide sensors for use with an interstitial continuous glucose monitor (A9276).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure provided on December 29, 2020.

You asked the Plan to pay for the prophylaxis and preventive procedure. You say that this claim should be covered. The Plan denied your request. The Plan says a separate fee for infection control is not a benefit 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. Therefore, we decided that the Plan does not have to pay for the preventive procedure provided on December 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal fusion surgery.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that the enrollee has failed over 15 years of conservative approaches to treatment. The Plan denied your request. The Plan says a review of the current medical literature indicates 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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is indicated for individuals with moderate lumbar stenosis. In this case, imaging states that the enrollee has severe spinal stenosis. The elements of the coverage rules are not satisfied. The requested procedure cannot be 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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal fusion surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network dialysis center.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.

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 network provider 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-approve a referral to an out-of-network dialysis center.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 21, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician 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 by the member's primary care physician. The Plan says that the referring provider is 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 for physician services provided on April 21, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit (CPT code 99214) to be provided by an out-of-network provider.

You asked the Plan to pre-approve the office visit. You say that this is for a routine follow-up. The Plan denied your request. The Plan says this provider is not an out-of-network provider because he terminated his contract effective January 1, 2021. The Plan states the services can be rendered by an in-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 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 network provider 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-approve the office visit (CPT code 99214) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) and imaging services (73610, 72170) provided on December 15, 2020 by an out of network (OON) provider.

You asked the Plan to pay for an OON office visit and imaging services. You say that the enrollee previously saw this provider. The Plan denied your request. The Plan says these 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 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 office visit (99213) and imaging services (73610, 72170) provided on December 15, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), intraoral periapical x-rays (D0220, D0230), bitewing x-rays (D0274) and a dental cleaning (D1110) provided on December 1, 2020.
You asked the Plan to pay for the dental services. You say that these services are covered up to three times per year and you have only been to the dentist one other time this year. The Plan denied your request. The Plan says you had another bitewing x-ray procedure in May of 2020. This service can only be covered once per plan year. In addition, you have already exhausted your $1,000 maximum for dental services for the year. Therefore, payment cannot be made for any dental services provided on the date in question.
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 may have frequency limitations for some covered services, and the Plan will cover a maximum of $1,000 each year. You are responsible for the charges that exceed this amount. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services were provided in excess of what is covered under this benefit. Documentation showed that you had bitewing x-rays performed and paid for by the Plan in May of 2020. The documentation also showed claims for dental services provided in June in an amount that exceeded the maximum $1,000 allowed by the Plan. At the time of service, your annual allowance had been depleted.
Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), intraoral periapical x-rays (D0220, D0230), bitewing x-rays (D0274) and a dental cleaning (D1110) provided on December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve a home ventilator. You say that this service is medically necessary. The Plan denied your request. The Plan says the rules for a home ventilator have not been met.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.

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 a home ventilator. Our reviewer says that the home ventilator is not medically necessary and reasonable. Our physician reviewer found based on the medical records provided there is documentation that you have thoracic restrictive disease based on total lung capacity "likely due to pulmonary edema and obesity." Provided records repeatedly indicate you do not have chronic obstructive pulmonary disease and report that she has chronic hypoxemic and hypercapnic respiratory failure due to obesity hypoventilation syndrome and diastolic heart failure. However, there is no documentation that the ventilator at issue is medically necessary and reasonable for you as records do not indicate that you have failed or would likely fail a Bilevel Positive Airway Pressure (BiPAP) device with average volume-assured pressure support (AVAPS) adaptive-servo ventilation technology.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for lab work provided by a participating provider on December 9, 2020.

You asked the Plan to waive the co-payment for lab work. You say that you have never had to pay for lab work before. The Plan denied your request. The Plan says the correct co-payment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 co-payment for outpatient diagnostic tests/lab services.

You have been asked to pay $27.90 which is less than your co-payment amount of $30 for lab work. The correct co-payment has been applied to the services that were provided. Lab work falls within the outpatient diagnostic tests/lab services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for lab work provided by a participating provider on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for family psychotherapy (90847) provided on July 9, 2020.
You asked the Plan to pay for family psychotherapy. You say that this is supported in the records. The Plan denied your request. The Plan says the records indicate that this was a one-on-one rather than a family session.
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 90847 is family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes. We find that CPT code 90847 is not supported in the medical record. Specifically, the records indicate that only the patient was present for the session at issue. Based on this information, we decided that Medicare rules for coverage of family psychotherapy have not been met. Therefore, we decided that the Plan does not have to pay for family psychotherapy (90847) provided on July 9, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a diagnostic medial branch block.

You asked the Plan to pre-approve a diagnostic medial branch block. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

Review of the file shows that the Plan uses Local Coverage Determination (LCD) L34832 to support their denial. However, LCD L34832 is retired. Therefore, we are unable to use LCD L34832 to substantiate our decision.

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 a diagnostic medical branch block. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found you have chronic neck pain. You are taking Gabapentin, Percocet, Mobic and Tizanidine for pain. You have attended Physical Therapy. The request meets the standard of care for a first set of diagnostic medial branch blocks. Therefore, you meet criteria for the requested 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 a diagnostic medial branch block have been met. Therefore, we decided that the Plan has to pre-approve a diagnostic medial branch block.

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, prophylaxis, first intraoral periapical x-ray, panoramic x-ray, and adjunctive pre-diagnostic test provided on January 7, 2021.

You asked the Plan to pay for the first intraoral periapical x-ray, panoramic x-ray, and adjunctive pre-diagnostic test. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered.

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. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, prophylaxis, first intraoral periapical x-ray, panoramic x-ray, and adjunctive pre-diagnostic test provided on January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for laboratory testing provided on January 27, 2021.

You asked the Plan to waive the co-payment for lab tests. You say that your office drew blood and sent it to a hospital facility without your knowledge, and it is not your responsibility to tell the physician office where to send labs to be processed. The Plan denied your request. The Plan says the co-payment amount you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $50 co-payment for in-network lab services at an outpatient hospital.

You have been asked to pay the allowed amount of $33.66, which is less than the $50 co-payment for lab tests. Lab tests fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 co-payment for laboratory testing provided on January 27, 2021.

Your complaint regarding your doctor sending your lab work to a hospital facility without your knowledge is considered to be a grievance. Maximus Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the periodic oral evaluation (D0120) and the prophylaxis (D1110) received January 12, 2021.
You asked the Plan to pay an additional amount for the periodic oral evaluation and the prophylaxis. You say that the Plan should provide additional reimbursement for the claim. The Plan denied your request. The Plan says if you choose to see an Out-of-Network dentist you might be billed for charges above what the plan pays, even for services listed as $0 copayment.
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 those those covered under this benefit. If you choose to see an Out-of-Network dentist you might be billed for charges above what the plan pays, even for services listed as $0 copayment. The Plan has agreed to pay up to 100% of the allowed amount for the requested services. You are responsible for any remaining balance charged by the Out-of-Network provider. Therefore, we decided that the Plan does not have to pay an additional amount for the periodic oral evaluation (D0120) and the prophylaxis (D1110) received January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision supply, accessory and/or service component of another vision code and Fundus photography provided on December 31, 2020.

You asked the Plan to pay for the vision supply, accessory and/or service component of another vision code and Fundus photography. The Plan denied your request. The Plan says these services are not covered benefits.

Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows that the Plan vision benefit includes routine eye exam that includes refraction and dilation. Therefore, we decided that the Plan does not have to pay for vision supply, accessory and/or service component of another vision code and Fundus photography provided on
December 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you disagree with the denial. The Plan
denied your request. The Plan says the services are not covered.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.