Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and cone beam computed tomography (CT) capture (D0365) provided on June 7, 2021.  You asked the Plan to pay for the dental services. You say that the only option for an oral surgeon in network would have been an hour away. You say that you are not able to drive a long distance. You say that you did not have a choice but to go to this provider's office. You also say that you cannot afford to pay this bill as you have a very minimal income. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services received out of network are not covered. The Plan also says that there are a substantial number of in network oral surgeons available closer than 1 hour.  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 received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and cone beam computed tomography (CT) capture (D0365) provided on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abutment supported retainer crown (D6069) and implant supported retainer crown (D6076) provided on March 25, 2021.  You asked the Plan to pay for the abutment supported retainer crown (D6069) and implant supported retainer crown (D6076). You say that your benefits booklet says major restorative procedures are covered with 70% coinsurance. You say that since you have comprehensive dental you thought it would be covered. The Plan denied your request. The Plan says the services are not covered benefits.  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 abutment supported retainer crown (D6069) and implant supported retainer crown (D6076) provided on March 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance intercept (A0432) provided on July 7, 2021.  You asked the Plan to pay for the ambulance service. You say that the ambulance that was called should provide the appropriate emergency personnel without having to call for outside help. You also say that the paramedic intercept services should be covered. The Plan denied your request. The Plan says the paramedic intercept service was not rendered in a rural area or rural New York. The Plan also says that there is no contract between the two ambulance providers.  The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York.  The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the ambulance intercept (A0432) provided on July 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on March 23, 2021.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. 

We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 genetic testing provided on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oral exam (D0120), initial periapical x-ray (D0220), additional periapical x-ray (D0230 x 2), bitewing x-rays (D0274), and periodontal maintenance (D4910) provided on July 20, 2021.  You asked the Plan to pay for the dental services. You say that your dentist was never told that they needed to get credentialed again. You also say that they are trying to get accredited again but have not heard back from your plan. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that the dental services received out of network are not covered. The Plan also says that periapical x-rays and periodontal maintenance are not listed as covered services.  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 received out of network are not among those covered under this benefit. Additionally, periapical x-rays and periodontal maintenance are not covered regardless of the provider's network status. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), initial periapical x-ray (D0220), additional periapical x-ray (D0230 x 2), bitewing x-rays (D0274), and periodontal maintenance (D4910) provided on July 20, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve patent foramen ovale (PFO) closure device placement for the enrollee.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that that records sent show that the enrollee's excursion is 10 mm, but not greater.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   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 requested services are considered medically reasonable and necessary in this case. Denial of this request was made in light of guideline requirement of a septum primum excursion of more than 10mm to qualify for approval; this patient's excursion was 10mm but not greater. However, the records refer to the dimension as being approximately 10mm, so it is possible that the 10mm dimension may have been slightly exceeded. In any case, the PFO size is borderline. In addition, the patient's age is just over the upper age recommendation of 60 years, while guideline point to a recommended age limit of 60 years. In short, this is a borderline case for which denial was primarily based on a PFO excursion dimension which is difficult to quantify with precision from trans-esophageal echocardiography imaging. However, the patient has had a documented cryptogenic stroke with other etiologies excluded, has a confirmed PFO with right to left shunting on Valsalva maneuver, and has had a subdural hematoma requiring craniotomy while on anticoagulation. Thus, the practitioner makes a reasoned, cogent argument for PFO closure given the limited treatment alternatives. Our physician reviewer found that the enrollee's condition meets criteria for coverage of these 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 these services have been met. Therefore, we decided that the Plan has to pre-approve patent foramen ovale (PFO) closure device placement for the enrollee.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eyeglasses (V2025, V2300) and eye exam (S0621) provided on July 26, 2021.  You asked the Plan to pay for the vision services. You say that you are on a fixed income and chose this provider because the overall cost of glasses would be cheaper for you. The Plan denied your request. The Plan says the provider in this case is not part of the Plan's specified routine vision care network. Only services received in-network are eligible for coverage.  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 they are received from a provider in the specified routine vision care network.  We looked at the file and the Plan's rules. The provider in this case does not participate in the specified routine vision care network. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2025, V2300) and eye exam (S0621) provided on July 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cell enumeration testing rendered on July 21, 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 were not medically 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of secondary malignant neoplasm of the right and left lungs and secondary malignant neoplasm of bone. It appears that the enrollee had metastatic castration-resistant prostate cancer.  The submitted documentation contains the Results of Circulating Tumor Cells, as well as multiple other laboratory test results. There are no additional clinical records for review. The documentation does not support that the testing was reasonable and medically necessary for the enrollee.  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 pay for the cell enumeration testing rendered on July 21, 2021.   The Local Coverage Determinations (LCDs) referenced by the Plan are not binding for the state of Texas where the testing was performed and were not used in the MAXIMUS review.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a myoelectric elbow-wrist-hand-finger orthosis for the enrollee.  You asked the Plan to pre-approve the orthosis. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem.  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 orthosis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated (L8702) is not medically necessary. At this time, the requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or  to improve the functioning of a malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities.  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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a myoelectric elbow-wrist-hand-finger orthosis for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital care provided August 11, 2020 to August 18, 2020.  You asked the Plan to pay for the inpatient hospital care. You say that DRG 177 was correctly billed. The Plan denied your request. The Plan says the services at issue are more appropriately described by DRG 178.  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 177, defined as Respiratory Infections and Inflammations with major complications or comorbidities. 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 hospital care. Our reviewer says that DRG 177 is not supported. Our physician reviewer found the review indicates that the documentation supported an admission for pneumonia. The documentation was inconsistent regarding a diagnosis of acute respiratory failure with hypoxia and mediastinum disease.   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 hospital care provided August 11, 2020 to August 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the knee immobilizer (L1380), provided on June 25, 2021.  You asked the Plan to pay for the knee immobilizer. You say that the item is medically necessary. The Plan denied your request. The Plan says there is no documentation of recent injury or surgery to the knee.  The Plan must follow Medicare rules. Medicare rules say that a knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s).    We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee immobilizer have not been met. Therefore, we decided that the Plan does not have to pay for the knee immobilizer (L1380), provided on June 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the hospital observation stay you had from July 28, 2021, to July 29, 2021.  You asked the Plan to waive the copayment for the hospital observation services. You say that you do not think you were an inpatient, so you should only have a $80 copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $300 copayment for outpatient hospital observation stays.   We looked at the medical records in this case.  The medical records show that although you were initially seen in the emergency room, you were moved to a room and kept overnight in observation. You have been asked to pay a $300 copayment for the hospital observation services. 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 hospital observation stay you had from July 28, 2021, to July 29, 2021.
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 IRF care is medically necessary for the enrollee to improve function and return to baseline. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the services they need in an alternate setting.

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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675).

You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. The Plan denied your request. The Plan says this device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CxBladder testing provided on February 4, 2021.  You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.  The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for are non-covered for CxBladder testing.   We looked at the file and Medicare rules. The CxBladder testing in this case was billed with code 0012M. This is not a covered code for CxBladder testing. 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 CxBladder testing provided on February 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for foot orthotics.  You asked the Plan to pay for foot orthotics. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.