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

We decided that the Plan does not have to pay for the Guardant360 testing (CPT code 81479) provided to the enrollee on September 10, 2020.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the provider did not confirm about the order for genetic testing.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. The Plan did multiple outreach with ordering provider and they did not confirm about the order for genetic testing. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing (CPT code 81479) provided to the enrollee on September 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and the ground mileage (A0425) provided on August 7, 2020.
You asked the Plan to pay for the ambulance services. You say that the services should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and the ground mileage (A0425) provided on August 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82378, 80048, 80076,
82306, 82728, 83540, 83550, 86300, 85025) provided to the enrollee on March 22, 2021, by an out-of-network
provider.
You asked the Plan to pay for the laboratory services. You say that this should be considered as in-network.
The Plan denied your request. The Plan says the enrollee's primary care provider was contacted on July 16,
2021, and it was confirmed a referral was not made.
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.
This service was denied because this is an exact duplicate claim/service (CPT code 82306). Furthermore, 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 the laboratory services (CPT code(s): 82378,
80048, 80076, 82306, 82728, 83540, 83550, 86300, 85025) provided to the enrollee on March 22, 2021, by an
out-of-network provider
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided by a Licensed Professional Counselor from February 3, 2021, to February 17, 2021.
You asked the Plan to pay for psychotherapy services. You say that you have been seeing this therapist for years. The Plan denied your request. The Plan says this provider is not enrolled in Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90837) provided by a Licensed Professional Counselor from February 3, 2021, to February 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
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 Prolia (J0897).
Benefits for Prolia 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020) and spherocylinder bifocal lenses (V2103) provided on March 18, 2021.
You asked the Plan to pay for eyeglass frames and bifocal lenses. You say that you visited the vision center, and this should be in-network as you have received your glasses from there prior. You also say the provider would not submit the bill themselves. The Plan denied your request. The Plan says eyewear will only be covered when they are received from a provider in the specified vision network.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan gives the member a $250 allowance, every two years for covered eye wear purchased from a network provider. The Plan also says the member is responsible for all costs for eye wear purchased from an out-of-network provider. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. The Plan covers eyewear when they are received from a provider who participates in the Plan's specified vision network. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames and bifocal lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020) and spherocylinder bifocal lenses (V2103) provided on March 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Avastin administration provided on June 6, 2020.
You asked the Plan to pay for the Avastin administration. You say that Avastin is the preferred treatment and is
the least expensive option. You also say that subsequent to the first injection of Avastin, you have received
treatment at your expense about every two months. The Plan denied your request. The Plan says this is not a
covered service according to your plan of benefits.
The Plan must follow Medicare rules. Medicare rules say that except in limited circumstances, Medicare does
not pay for services furnished outside the United States.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Avastin administration have not been met. Therefore, we decided that the Plan does not have to
pay for the Avastin administration provided on June 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 9 and 11, and a pontic (D6245) for tooth # 10.
You asked the Plan to pre-approve the dental services. You say that you have $4,000 in dental coverage. You also say that these services should have been approved. The Plan denied your request. The Plan says retainer crowns are not listed as covered services. The Plan says that pontic is not listed as a covered service either.
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 retainer crowns and pontic are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 9 and 11, and a pontic (D6245) for tooth # 10.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee to
be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve SNF services. You say that the enrollee would not be happy in a nursing
home and should be in a thriving facility. The Plan denied your request. The Plan says that there is no
indication for admission to a SNF that is not contracted with the Plan.
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
skilled nursing facility (SNF) services for the enrollee to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve InterDry dressings, skin sealants, protectants, moisturizers, ointments, any type (A6250).

You asked the Plan to pre-approve InterDry dressings. You say that it is important that the enrollee continue to use InterDry cloths to prevent infected skin lesions from forming. The Plan denied your request. The Plan says this item is not covered under the surgical dressing benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6250 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve InterDry dressings, skin sealants, protectants, moisturizers, ointments, any type (A6250).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 3 and 4 and retainer crowns (D6750) for tooth #'s 2 and 5.

You asked the Plan to pre-approve the pontics and retainer crowns. You say that there is a piece missing in your mouth and you are having issues chewing, and it is causing you sores in your mouth. You also say that having a bridge will benefit you in more than one way. The Plan denied your request. The Plan says a bridge is only allowed if you are missing one front tooth.

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 pontics (D6240) for tooth #'s 3 and 4 and retainer crowns (D6750) for tooth #'s 2 and 5 are not covered because these teeth are all posterior teeth, and your plan only allows fixed bridgework coverage for permanent anterior teeth. Therefore, we decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 3 and 4 and retainer crowns (D6750) for tooth #'s 2 and 5.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services provided from December 10, 2020,
to December 15, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed
code cannot be verified.

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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in
the medical record. Specifically, the records do not indicate the amount of time the physician spent with the
enrollee on each date of service at issue. 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 critical care services provided from December 10, 2020, to December 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the visit you had with a hospitalist on November 25, 2020.
You asked the Plan to reduce the copayment for the hospitalist visit. You say that this doctor is your primary care doctor and not a specialist. The Plan denied your request. The Plan says this copayment was charged 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 $50 copayment for visits with a specialist. You have been asked to pay a $50 copayment for the hospitalist visit. Records show that the provider has a specialty of 'hospitalist'. This doctor is not considered a primary care doctor. 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 reduce the copayment for the visit you had with a hospitalist on November 25, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from IRF care to optimize
her level of functioning prior to returning home. The Plan denied your request. The Plan says criteria for
admission to the IRF setting have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multidisciplinary
rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of an impacted tooth (D7241) for tooth #17 and tooth #32.

You asked the Plan to pre-approve removal of impacted teeth.. You say that this service is necessary for these teeth. The Plan denied your request. The Plan says this service is not covered by your dental benefit.

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 pre-approve removal of an impacted tooth (D7241) for tooth #17 and tooth #32.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT, head or brain; without contrast material (CPT code 70450-26) provided to the enrollee on January 7, 2021.
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says this service was already paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT code 70450-26 is not supported in the medical record. The enrollee had professional interpretation of a head CT on January 7, 2021. The submitted documentation supports 1 (one) unit of 70450-26, which was previously approved/paid. There is no additional documentation supporting an additional study which was billed and remains denied. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for CT, head or brain; without contrast material (CPT code 70450-26) provided to the enrollee on January 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prefabricated abutments (D6056 x3).

You asked the Plan to pre-approve prefabricated abutments. You say that the service at issue is medically necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

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 pre-approve prefabricated abutments (D6056 x3).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you from January 5, 2021, to February 24, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not eligible for payment.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Licensed professional counselors are not eligible to enrollee in the Medicare program. Therefore, we decided that the Plan does not have to pay for the services provided to you from January 5, 2021, to February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for subsequent hospital care (99233) provided December 31, 2020.
You asked the Plan to pay for subsequent hospital care (99233). You say that this claim should be paid. The
Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans
denial. The Plan requested a reopen and provided additional information. The Plan says this claim requires a
corrected claim with a 77 modifier which is required to show this is a repeat procedure. The Plan confirmed
this code was previously paid to another physician for the same date of service for the same enrollee.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one
service is provided on the same day to the same patient by the same physician or more than one physician in
the same specialty in the same group, only one service may be reported unless the services are for unrelated
problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group
relationship between the two providers and the omission of the modifier required to identify this as a separate
and distinct service or a repeat service. Medicare billing criteria were not met. Therefore, we decided that the
Plan does not have to pay for subsequent hospital care (99233) provided December 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says large population sufficiently powered randomized controlled trials that demonstrate
long-term health outcome advantages are needed for this procedure.
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 procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this procedure is experimental. More research is needed to show safety and efficacy of the
Intracept procedure.
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-approve the Intracept procedure for the enrollee