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

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 31, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this should be reported with CPT 81479. 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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 laboratory services provided to the enrollee on March 31, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the services the enrollee requires can safely be received at a different setting.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve ten additional months of rental of a manual wheelchair.  You asked the Plan to pre-approve the additional months. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of information about current mobility status.  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 additional months. Our reviewer says that the requested additional months are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation is not clear on your mobility limitation, and the extent that impairs the ability complete MRADLs. The documentation does not reveal that the requested wheelchair rental is medically necessary beyond what was approved by the health plan therefore the lower seat height with K0002 and the E0974 are also not medically necessary.  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 additional months have not been met. Therefore, we decided that the Plan does not have to pre-approve ten additional months of rental of a manual wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation and cone beam CT capture provided on July 27, 2021.

You asked the Plan to pay for the limited oral evaluation and cone beam CT capture. You say that you needed to have multiple x-rays and was informed you needed the CT cone beam. You say that you were informed you would be refunded if insurance paid. The Plan denied your request. The Plan says you pay the charges beyond the $1,000 allowance.

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, you also have a maximum benefit of $1,000 every year for covered dental services. The Plan already paid $1,000 toward the dental services received in the 2021 calendar year, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation and cone beam CT capture provided on July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).  You asked the Plan to pre-approve genicular RFA. You say that your pain is so severe that you cannot walk. The Plan denied your request. The Plan says the denial of authorization is correct, because genicular RFA is still being studied for efficacy.  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 genicular RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental/investigational as it is still the subject of ongoing clinical trials.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the photochemotherapy (96910) rendered by the out-of-network (OON) provider on October 7, 2020.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  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 the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the photochemotherapy (96910) rendered by the out-of-network (OON) provider on October 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an alignable system (L5910).  You asked the Plan to pre-approve an alignable system. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation that this is necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an alignable system. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested component cannot be used with the enrollee's preparatory prosthesis and would exceed the enrollee's medical need.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an alignable system have not been met. Therefore, we decided that the Plan does not have to pre-approve an alignable system (L5910).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the BioFIRE GI pathogens panel.  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 testing is not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the BioFIRE GI pathogens panel.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance services (A0428, A0425) provided on July 8, 2021.  You asked the Plan to pay for ambulance services. You say that this was medically necessary. The Plan denied your request. The Plan says the enrollee was an inpatient at the time of service.  The Plan must follow Medicare rules. Medicare rules say that all items and nonphysician services, including transportation, furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  We looked at the file and Medicare rules. The records show that enrollee was an inpatient on the date of service at issue, meaning that the hospital is responsible for the payment or billing of this service. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0428, A0425) provided on July 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) provided May 18, 2021.  You asked the Plan to waive the copayment for the non-emergency ambulance transport. You say that you were not informed there would be a charge for the transportation. 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 $250 copayment for each one-way Medicare-covered ground ambulance trip.     You have been asked to pay a $250 copayment for the non-emergency ambulance transport. The non-emergency ambulance transport falls within the Ambulance 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 copayment for the ambulance service, basic life support, non-emergency transport (A0428) provided May 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computed tomography (CT) calcium scoring scan.  You asked the Plan to pre-approve CT scan. You say that imaging showed that you have some plaque on your heart and now you need to have further testing done. The Plan denied your request. The Plan says the denial of authorization for this test is correct, because you do not meet the criteria for CT calcium scoring.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.   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 CT scan. Our reviewer says that you do not meet the Medicare criteria for the requested CT calcium scoring scan. Our physician reviewer found you were seen for an annual examination on September 9, 2021 and were asymptomatic. You were diagnosed with coronary artery disease (CAD) in September 2020 by cardiac CT angiography, with a calcium score of 3220, severe aortic calcification. You fail to meet the clinical guideline criteria because you already have a diagnosis of CAD. Therefore, this CT scan is not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) calcium scoring scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided June 15, 2020 to June 21, 2020.

You asked the Plan to pay for the inpatient care. You say that DRG 193 was correctly billed. The Plan denied your request. The Plan says DRG 194 is more appropriate based on the records provided.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. 

In this case, you billed the inpatient services provided with DRG 193. 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 inpatient care. Our reviewer says that DRG 193 is not supported in the records. Our physician reviewer found the reviewed documentation supported an admission for pneumonia. The documentation was inconsistent regarding a diagnosis of acute and chronic respiratory failure with hypercapnia. Even though acute and chronic respiratory failure with hypercapnia is documented in the progress notes and discharge summary, supporting medical record documentation was not found within the records. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient care provided June 15, 2020 to June 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on June 12, 2021 to June 13, 2021.

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. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 

We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on June 12, 2021 to June 13, 2021.

Benefits for these services 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach (CPT code 33361) provided to the enrollee on June 21, 2021.  You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed.  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 services have not been met. A review of the claims system shows Clinical Trial number was not billed as per Medicare. The denial for Clinical Trial number per the 2150. Review for Coverage with Evidence Development (CED) Review is required criteria defined by the appropriate National Coverage Determination or a Reimbursement policy. Therefore, we find the Medicare rules for payment as not been met. If the provider determines that a billing error occurred during the initial submission of the denied claim, the Plan would accept a submission of a corrected claim to consider for payment. Therefore, we decided that the Plan does not have to pay for transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach (CPT code 33361) provided to the enrollee on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for the crown (D2740)07 provided on June 3, 2021.  You asked the Plan to pay an additional amount for the dental service. You say that you understand core build up is not a covered service. You also say that you feel more should have been paid towards the crown. The Plan denied your request. The Plan says crowns received out of network have a 75% coinsurance. The Plan says that the crown was billed at $979 and 25% of the in network fee schedule (INFS) amount of $621.00 was correctly paid, equaling $155.25. Your responsibility for the crown is made up of 75% of $621 ($465.75) plus the difference ($358) between the billed amount and the INFS.  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 crowns are listed as covered, out of network dentists may bill you for any amount greater than what the plan pays. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay an additional amount for the crown (D2740)07 provided on June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 8, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on July 20, 2021.  You asked the Plan to pay for the occlusal guard (D9944). The Plan denied your request. The Plan says the service 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 pay for the occlusal guard (D9944) provided on July 20, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the pharmacogenomics (PGx) testing panel provided on February 24, 2021.

You asked the Plan to pay for the PGx panel. You say that this was considered medically necessary by the ordering provider and should be covered. The Plan denied your request. The Plan says that this was billed with more than one code. The National Correct Coding Initiative (NCCI) rules state that when two or more genes are tested in parallel, it is a single panel and must be billed with one code. This cannot be overridden by plan-directed care.

Maximus reviewed the NCCI rules cited by the Plan. We find that these rules indicate that such a panel may either be billed with one unit of 81479 or for the individual genes tested. As such, there is no clear Medicare rule cited which disallows billing this panel with multiple codes.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.

The enrollee was referred for the PGx panel by a contract provider. The file does not show that the plan provided notice that the PGx panel would not be covered. Under Medicare rules, this means the PGx panel is considered approved by the plan. Therefore, we decided that the Plan has to pay for the pharmacogenomics (PGx) testing panel provided on February 24, 2021.

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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the neuromuscular stimulator electronic shock unit provided from August 25, 2020, to June 25, 2021.  You asked the Plan to waive the coinsurance for the neuromuscular stimulator electronic shock unit. You say that you were never informed this was a rental and that you would be charged monthly.  The Plan denied your request. The Plan says the claims for December 25, 2020, January 25, 2021, and June 25, 2021, have been reprocessed and you have been asked to pay the correct cost-sharing amount for all the dates of service.   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 durable medical equipment provided by an in-network durable medical equipment provider.   You have been asked to pay $1,025.48 which is 20% of the allowed amounts for the neuromuscular stimulator electronic shock unit. The neuromuscular stimulator electronic shock unit falls within the "Durable medical equipment (DME) and related supplies" benefit category. See chart below.  Date of Service Service Allowed Amount Coinsurance Member Liability August 25, 2020 Neuromuscular unit $4,233.63 20% $846.72 September 25, 2020 Neuromuscular unit $96.81 20% $19.36 October 25, 2020 Neuromuscular unit $96.81 20% $19.36 November 25, 2020 Neuromuscular unit $96.81 20% $19.36 December 25, 2020 Neuromuscular unit $96.81 20% $19.36 January 25, 2021 Neuromuscular unit $97.00 20% $19.40 February 25, 2021 Neuromuscular unit $104.21 20% $20.84 March 25, 2021 Neuromuscular unit $104.21 20% $20.84 April 25, 2021 Neuromuscular unit $104.21 20% $20.84 June 25, 2021 Neuromuscular unit $97.00 20% $19.40 Total    $1,025.48   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 neuromuscular stimulator electronic shock unit provided from August 25, 2020, to June 25, 2021.