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

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1(A0427) and ground mileage (A0425) provided October 26, 2020.

You asked the Plan to waive the copayment for the emergency ambulance services. You say that you feel this copayment should be waived because the service was related to coronavirus (COVID-19). The Plan denied your request. The Plan says the copayment was applied correctly. Copayments for ambulance services related to COVID-19 were not waived.

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 $240 copayment for ground travel by ambulance. 

You have been asked to pay a $240 copayment for the emergency ambulance services. The emergency
ambulance services fall within the Ambulance services benefit category. The Plan's COVID-19 waiver does not cover copayments related to ambulance services. Additionally, the COVID-19 waiver only covers services provided by network providers. The ambulance provider in this case is not a network provider with the Plan. 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 ambulance service, advanced life support, emergency transport, level 1(A0427) and ground mileage (A0425) provided October 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. 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.       

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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the colonoscopy with lesion removal (45385) provided on July 27, 2021.

You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $200 copayment for each covered surgery or observation room service in an outpatient hospital.

You have been asked to pay a $200 copayment for the surgery provided in an outpatient hospital. 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 adjust the copayment for the colonoscopy with lesion removal (45385) provided on July 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron for the enrollee.

You asked the Plan to pre-approve this drug. You say that the enrollee needs this drug for prevention or treatment of nausea and vomiting associated with cancer chemotherapy. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron for the enrollee.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic mammography (77065) provided on July 20, 
2021.

You asked the Plan to pay for the diagnostic mammography. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says a procedure to procedure edit 
exists between codes 77065 and 77066.

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, we have confirmed that code 77065 
is a column II code to column I code 77066. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the diagnostic mammography (77065) provided on July 20, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care for evaluation and management of the 
enrollee (99223) provided on April 6, 2021.

You asked the Plan to pay this claim. You say that this claim should be paid. The Plan denied your request. 
The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested 
are reopen and stated that this claim denied because this service is considered as being a part of the global
surgical package of major procedure (90-global days). The Plan states these services were paid under a 
previous claim. The case file includes the claim images for the appealed and referring claims that show both 
claims were billed by the same provider group. 

The Plan states that the Medicare Claims Processing Manual Chapter 12 - Section 40.1 A explains, components 
of the global surgical package include "preoperative visits after the decision are made to operate beginning 
with the day before the day of surgery for major procedures is included in the global surgical package of that 
major procedure and the day of surgery for minor procedures." The Plan also states that, per Medicare Claim s 
Processing Manual Chapter 12 - Section 40.1 C explains, visits by the same physician on the same day as a 
minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately 
identifiable service is also performed. Review of the medical record indicates that the service performed was 
unrelated to the major procedure performed on April 6, 2021; as it states the patient is present to the emergency 
room complaining of right lower abdominal pain. On examination, he was tender in the right lower quadrant 
and he has a positive roving sign, they decided laparoscopic appendectomy. However, the provider did not bill 
a modifier indicating that the decision for surgery was made during the evaluation and management.

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. In this case, this claim 
cannot be paid as billed due to the inappropriate billing by the provider to demonstrate a defined service with 
the appropriate modifier. Medicare rules for coverage of this claim have not been met. Therefore, we decided 
that the Plan does not have to pay for initial hospital care for evaluation and management of the enrollee 
(99223) provided on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Hako-Med bioelectric therapy and Nutri-Pharmaceutical 
blend injection (J3420, J2001 and G0283) provided on July 6, 2021.

You asked the Plan to pay for the Hako-Med bioelectric therapy and Nutri-Pharmaceutical blend injection. You 
say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan 
says these services are considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical 
therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private 
practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that 
NP/PA may perform physical therapy services under State law. The rules also say that claims for compounded 
drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Hako-Med bioelectric therapy and Nutri-Pharmaceutical blend injection have not been met. 
Specifically, review of the file and publicly available records, we find that the physical therapy services at issue
in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Ohio. 
Additionally, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin 
syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. 
As this compounded drug was not billed properly, payment cannot be made. Therefore, we decided that the 
Plan does not have to pay for the Hako-Med bioelectric therapy and Nutri-Pharmaceutical blend injection 
(J3420, J2001 and G0283) provided on July 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay anything further for positron emission tomography and
Fluciclovine provided on November 27, 2019.

You asked the Plan to pay anything further for these services. You say that this claim should be paid. The Plan
denied your request. The Plan says Medicare billing criteria were not met. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim
processed with the Plan as the secondary payer. The records show the Plan coordinated benefits with the
primary insurance carrier and found they made a payment of $1,579.26 towards this claim. The Explanation of
Benefits shows that the Plan paid $240.72 as the secondary insurance carrier. The Plan showed documentation
that no further payment is required for these services.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules state that Medicare plans are
considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not
responsible for paying for services until the claim for those services has gone to the primary insurer. However,
plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits
with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for
payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can
pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has shown the
communicated with your primary insurance payer and paid on the balance owed on the claim. As the secondary
insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for
these services. Therefore, we decided that the Plan does not have to pay anything further for positron emission
tomography and Fluciclovine provided on November 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria.

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 appears to be improving and should only require short-term additional 
acute care services that can safely be administered at the current facility. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at the current facility. Completion of care at 
the current location is recommended prior to transfer to a lower level of 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on September 22, 2020.  

You asked the Plan to pay for the services provided. You say that no coding change is required. The Plan denied your request. The Plan says the Z-code may only be principal/first listed diagnosis.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  

We looked at the file and the rules. The file shows that the diagnosis code at issue was not billed as a principle diagnosis. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the office visit provided on September 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the skin lesion shaving procedures provided 
on September 14, 2021.

You asked the Plan to waive the deductible for the skin lesion shaving procedures. You say that this procedure 
should be billed as an office visit and not as an outpatient procedure. The Plan denied your request. The Plan 
says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible which applies to the skin lesion shaving procedures.
. 
The skin lesion shaving procedures you asked the Plan to waive the deductible for falls within the "Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 
deductible which applies to the skin lesion shaving procedures. This cost sharing is a contractual obligation that 
had not been met at the time the skin lesion shaving procedures was received on September 14, 2021.
Therefore, we decided that the Plan does not have to waive the deductible for the skin lesion shaving 
procedures provided on September 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Udenyca (Q5111).

You asked the Plan to pre-approve Udenyca. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that administration of granulocyte colony stimulating factors (G-CSF) for primary prophylaxis should be reserved for those patients whose risk of febrile neutropenia (FN) is 20% or greater based upon chemotherapy regimen. In patients whose risk of developing FN is greater than or equal to 10% and less than 20% based on chemotherapy regimen, the use of primary prophylaxis should be reserved for those patients with one or more additional risk factors for FN. 

We looked at the file and Medicare rules. The records do no document a 10% or greater risk of FN. Based on this information, we decided that Medicare rules for coverage of Udenyca have not been met. Therefore, we decided that the Plan does not have to pre-approve Udenyca (Q5111).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the laboratory services and the electrocardiogram provided on July 16, 2021.  

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.  

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 $10 copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility). This excludes basic and advanced diagnostic imaging services.  

Additionally, diagnostic testing received during an annual wellness visit will be subject to diagnostic cost sharing.  

You have been asked to pay $30 ($10 copayment x 3) for the diagnostic laboratory services and the diagnostic test rendered by three providers. 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 for the laboratory services and the electrocardiogram provided on July 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no documentation of a requirement for frequent changes to the insulin regimen.

The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section.

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 monitor. Our reviewer says that the
requested monitor is not medically reasonable or necessary. Our physician reviewer found your medical
regimen does not include insulin therapy or a Medicare-covered continuous subcutaneous insulin infusion
pump.

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 monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve a continuous glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for imaging services provided to the enrollee on March 26, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization. Maximus overturned the Plans denial
stating this imaging was medically necessary. The Plan requested a reopen and stated that the issue was not
medical necessity but that the enrollee did not have prior authorization.
The Plan is correct in this case. 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 provider in this case is not a
network provider with the Plan. The Plan had network providers available who could have provided this
service. The Plan did not pre-approve this service. Therefore, we decided that the Plan does not have to pay for
imaging services provided to the enrollee on March 26, 2021
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the SelectMDx test provided to the enrollee on July 22, 2021.  

You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your request. The Plan says this testing has not met the technical assessment requirements.  

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this testing is denied as it is considered not reasonable and necessary according to Medicare criteria. The review has determined that the enrollee does not require this testing. This testing does not demonstrate clinical and analytical utility. This testing will not guide medical management.  

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the SelectMDx test provided to the enrollee on July 22, 2021.