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

We decided that the Plan does not have to waive the coinsurance for chemotherapy services you received on
August 11, 2021.
You asked the Plan to waive the coinsurance for the chemotherapy services. You say that you paid a lower
amount when you received these injections at a different facility. You feel as though you are being
overcharged. The Plan denied your request. The Plan says you have been charged this coinsurance correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for chemotherapy drugs.
You have been asked to pay 20% coinsurance for the chemotherapy services. The price for this drug is based
on the negotiated rate that the Plan has with this provider. Plans and providers are permitted to negotiate these
rates and Maximus does not have jurisdiction to assess whether or not those rates are too high. Our decision is
based solely on your contract language. Your contract says that you pay 20% coinsurance for chemotherapy
drugs, and that is what you have been charged.
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 chemotherapy services you received on August 11, 2021.
Your complaint about the negotiated rate for this drug is not a valid appeal for medical coverage. This part of
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (98943) additional supplies, equipment and staff time during the public health emergency (99072) provided August 26, 2021 to August 31, 2021.

You asked the Plan to pay for the chiropractic services. You say that please reprocess and pay the claim. The Plan denied your request. The Plan says this service is not a covered benefit. Procedure code 99072 is considered incidental to the total episode of care.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (98943) additional supplies, equipment and staff time during the public health emergency (99072) provided August 26, 2021 to August 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 81455 provided on June 29, 2021.

You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.

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 targeted genomic sequence analysis panel 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 targeted genomic sequence analysis panel coded 81455 provided on June 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 provided on April 15, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

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 codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in an office setting, place of service 11; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an Assisted Living Facility, place of service 13. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 provided on April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the deep sedation (D9222, D9223), and the extraction (D7210) provided on September 13, 2021.
You asked the Plan to reimburse you for the dental services. You say that you were referred to this dentist. You say that you were never advised by anyone that this provider had opted out of Medicare.
You also say that you were not advised that you would not be reimbursed for this claim. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made to a provider that has opted out of Medicare.
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, dental services performed by a provider that has opted out of Medicare are not among those covered under this benefit. Additionally, there is no record that you contacted the Plan prior to the date of service to confirm the provider's eligibility. Therefore, we decided that the Plan does not have to reimburse you for the deep sedation (D9222, D9223), and the extraction (D7210) provided on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a podiatry visit provided on October 13, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a podiatry visit. You say that you were unaware that prior authorization was needed for the visit. The Plan denied your request. The Plan says no prior authorization was obtained and there was no referral to see a specialist.

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 a podiatry visit provided on October 13, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (76705) provided August 23, 2021.
You asked the Plan to pay for the radiology services. You say that the radiology services were medically necessary. The Plan denied your request. The Plan says the billed code shares a bundled relationship with another code billed.
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 76705 is a column II code to column I code 93976. 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 radiology services (76705) provided August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia services provided on August 14, 2021, billed with code 99100.

You asked the Plan to pay for the special anesthesia services as billed. You say that you feel this should be paid since you are contracted to received $45 for this service. The Plan denied your request. The Plan says Medicare does not make separate payment for this service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

CPT code 99100 has a status indicator of "B" on the Physician Fee Schedule. This means that payment for this service is bundled with other services and not made separately. Based on this information, we decided that Medicare rules for coverage of the special anesthesia services as billed have not been met.

Therefore, we decided that the Plan does not have to pay for the special anesthesia services provided on August 14, 2021, billed with code 99100.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Clonazepam tablet 0.5mg for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this self-administered drug does not fall 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 Clonazepam tablet 0.5mg for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) provided May 20, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the eye refraction. You say that the provider was shown to be in-network. The Plan denied your request. The Plan says eye refractions are only covered when provided as part of a routine eye exam with a provider who participates with the Plan's third-party dental vendor.

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 covers these services when provided during a routine exam and performed by a routine vision care provider. 

We looked at the file and the Plan's rules. In this case the provider who rendered the services is not part of the Plan's routine vision care network. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) provided May 20, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for epidural steroid injection (62320) provided September 13, 2021.

You asked the Plan to pay for the injection services. You say that this code is not limited to just injecting corticosteroid preparations nor is it limited to the epidural space. The procedure you are billing for is subarachnoid injection of opioid medications. The Plan denied your request. The Plan says this provider has not submitted any clinical records to support the medical necessity of the services.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

In this case the provider has not submitted any clinical records to support the medical necessity of the services. The Plan made multiple attempts to obtain the medical records from the provider without success. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for epidural steroid injection (62320) provided September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99190, 99191) provided on June 4, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in the facility payment.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary.
The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (99190, 99191) provided on June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4341 x2)
provided on October 4, 2021.

You asked the Plan to pay for the scalings and planings. You say that you have always been on a paper billing
method and were surprised to find out when you called the Plan that you had been switched to the paperless
method without your knowledge or permission. You also say that you would not have scheduled dental work
for October if you knew it had been cancelled. The Plan denied your request. The Plan says you were not
eligible for coverage. The Plan also says that your plan offers a dental rider, but you were not enrolled in this
rider at the time of service.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the two periodontal scalings and
root planings (D4341 x2) provided on October 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 home health physical therapy visits.
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 not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee underwent a right total knee replacement on December 31, 2021. She started home health services on January 5, 2022 and is independent with walking 50 feet with a rollator walker. The records show she has not been compliant with the home exercise program due to memory issues. The records do not support that she has ongoing home health physical therapy needs. She is mobilizing independently and continued home health physical therapy is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 home health physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the records received show your condition has stabilized to the baseline of your severe dementia.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient psychiatric hospital services.

Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is not expected you will improve in a reasonable period of time as you do not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. You were compliant with treatment while not showing any acute threats to safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as you do not have dangerousness to yourself or others and were compliant with your treatment. Our physician reviewer found that your condition does not meet criteria for coverage of inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the radiation management (77427) and the
radiation treatment delivery (G6012) provided from September 1, 2021, through September 16, 2021.

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the coinsurance has 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 20%
coinsurance for the cost of therapeutic services.

You have been asked to pay $661.44 (Plan allowed amount of $3,307.20 x 20% coinsurance) for the radiation
therapy services provided. 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 radiation management
(77427) and the radiation treatment delivery (G6012) provided from September 1, 2021, through September 16,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a diabetic shoe for density insert (A5500) and a multiple
density insert for diabetics only (A5512) provided on May 7, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a diabetic shoe for density insert and a multiple density insert for diabetics only.
You say that you are appealing with supporting records. The Plan denied your request. The Plan says this claim
was denied for failure to obtain the required prior authorization, and it was determined the services were not
urgent or emergent in nature. The Plan also says that upon review, an authorization was not obtained prior to
the services being rendered and the provider is not participating with the member's 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 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 a diabetic shoe for density insert (A5500) and a
multiple density insert for diabetics only (A5512) provided on May 7, 2021, by an out-of-network (OON)
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services coded as 97813, 97814, 9781 97811 provided August 26, 2021 to August 10, 2021.

You asked the Plan to pay for the acupuncture services. You say that you went to an out of network acupuncturist for your chronic lower back pain because you could not find a provider in the Plan's directory. The Plan denied your request. The Plan says the acupuncture services were not documented to be under appropriate supervision by a physician, nurse practitioner, or physician assistant who meets the requirements.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the services were rendered by a licensed acupuncturist and not a physician. Therefore, we decided that the Plan does not have to pay for the acupuncture services coded as 97813, 97814, 9781 97811 provided August 26, 2021 to August 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transmitter, external for use with interstitial continuous glucose monitoring (A9277) for the enrollee.

You asked the Plan to pre-approve the transmitter. You say that this is medically necessary. The Plan denied your request. The Plan says that this is non-covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that CGM devices covered by Medicare under the DME benefit are defined as therapeutic CGMs and code A9277 is used to describe the supplies used with a non-therapeutic CGM. 

We looked at the file and Medicare rules. Based on this information, we decided that you are requesting supplies for a non-therapeutic CGM. Medicare will only cover therapeutic continuous glucose monitors and supplies.

Therefore, we decided that the Plan does not have to pre-approve transmitter, external for use with interstitial continuous glucose monitoring (A9277) for the enrollee.