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

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 26, 2021.

You asked the Plan to pay for the periodontal maintenance. You say that you should have only been charged $72.00 for this service. The Plan denied your request. The Plan says this service is not a covered benefit under your plan.

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 periodontal maintenance (D4910) provided on October 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathology testing provided to the enrollee on
September 13, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes
will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS code
must be submitted for the panel.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found no provider records have been submitted for review. Therefore, there is no evidence to support that the
provided services were medically necessary and reasonable to diagnose, treat or otherwise manage the
enrollee's condition(s).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have
to pay for the molecular pathology testing provided to the enrollee on September 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99211) provided on June 3, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that you request that these claims be promptly processed and paid for the services rendered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 the outpatient office visit (99211) provided on June 3, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).  You asked the Plan to pre-approve a pneumatic compression device. You say that this is medically reasonable for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  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 for a pneumatic compression device. Our reviewer says that based on the medical records provided there is no documentation that adequately satisfies the coverage criteria for the intermittent limb pneumatic compression device (E0652). Provided records do not document trial and failure of a four-week trial of conservative therapy including at least four weeks of regular, daily, multiple-hour home usage of a E0650 or E0651 pneumatic compression device after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this does not meet the medical necessity criteria.
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 the services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found that in this case,
the documentation doesn't support that the enrollee requires skilled rehab services to provide treatment that is
medically necessary. The enrollee does not require rehab services to effectively provide treatment, care, and/or
services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's
condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations
of chronic medical problems or hospitalizations. Her function has returned to baseline and she is independent
with a home exercise program. The additional therapy 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve home health services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81401, 81479, 82955) provided May 13, 2020.
You asked the Plan to pay for the lab services. You say that the testing performed was medically necessary. 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 the lab services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the provided service was medically necessary and reasonable to diagnose, treat, or otherwise manage the enrollee's condition. 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 lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81401, 81479, 82955) provided May 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Gemtesa  You asked the Plan to pre-approve Gemtesa. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says for your Medicare Part B benefit to cover the drug, it must be furnished by your physician, an infusion center, or the hospital outpatient department.  The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Gemtesa   Benefits for Gemtesa 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: 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 is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Purewick external catheter (A4328) provided on December 24, 2020 to July 22, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for Purewick external catheter. You say that you used the Purewick in the hospital and liked it so you wanted them for the home. You asked your doctor about them, but he told you they didn't carry them and wouldn't write a prescription. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 Purewick external catheter (A4328) provided on December 24, 2020 to July 22, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an office visit provided on June 2, 2021.  You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges because you should not owe a copayment to see your provider. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  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 $40 copayment for out-of-network primary care doctor visits.   You have been asked to pay a $40 copayment for an out-of-network office visit. An out-of-network office visit falls within the physician/practitioner services, including doctor's office visits 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 an office visit provided on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the caries risk assessment and documentation, with a finding of moderate risk (D0602) provided September 15, 2021.

You asked the Plan to pay for the caries risk assessment. You say that you would like this service covered. The Plan denied your request. The Plan says this service is not covered under your 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 caries risk assessment and documentation, with a finding of moderate risk (D0602) provided September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist services provided on September 22, 2020.
You asked the Plan to waive the copay for the services provided. The Plan denied your request. The Plan says the copay was applied per the enrollee's benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $15 copay for each covered visit in an outpatient location with a specialist. The enrollee has been asked to pay a $15 copay for the services provided. The services fall within the physician services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the specialist services provided on September 22, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 We decided that the Plan has to pre-approve a crown for tooth # 29. We decided that the Plan does not have to pre-approve a crown for tooth # 28.   You asked the Plan to pre-approve a crown for tooth # 29. You say that the requested crowns are necessary. The Plan denied your request. The Plan says the requested crowns are not medically necessary.  We decided that the Plan has to pre-approve a crown for tooth # 29.   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. The Plan covers crowns when the services are medically necessary and reasonable.   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 crowns. Our reviewer says that a crown for tooth # 29 is medically necessary. Our physician reviewer found that the provided documentation does reveal that the tooth had an existing three surface restoration with separation on the incisal aspect, involving the buccal cusp. Therefore, the reviewer found that there would be sufficient involvement of the structure on tooth # 29 as to meet the criteria.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown for tooth # 29 have been met. Specifically, the file indicates that tooth # 29 has significant breakdown that would warrant a full coverage crown. Therefore, we decided that the Plan has to pre-approve a crown for tooth # 29.   We also decided that the Plan does not have to pre-approve a crown for tooth # 28.  Our reviewer says that a crown for tooth # 28 is not medically necessary. Our physician reviewer found that the provided documentation does not indicate sufficient damage to the tooth to warrant the placement of a full coverage crown. Therefore, the reviewer found that the criteria for the requested crown for tooth # 28 does not meet the criteria.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown for tooth # 28 have not been met. Specifically, the file shows that tooth # 28 does not have significant damage that would warrant a full coverage crown. Therefore, we decided that the Plan does not have to pre-approve a crown for tooth # 28.  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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the no transport ambulance service (A0998), provided on July 23, 2021.

You asked the Plan to pay for the no transport ambulance service. You say that the service should be covered. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on July 23, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the no transport ambulance service (A0998), provided on July 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery to place a Vertiflex Superion device (CPT Code(s): 22869, 22870 and 99152).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is no discussion indicating that a DEXA scan has demonstrated no osteoporosis in this patient. Moderate spinal stenosis was not documented in detail at one-two adjacent lumbar levels. Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition. Therefore, this request does not meet Medicare criteria as medically reasonable and necessary for treatment of this enrollee's medical condition. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve surgery to place a Vertiflex Superion device (CPT Code(s): 22869, 22870 and 99152).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (88342, 88341) provided on August 20, 2021.  You asked the Plan to pay for laboratory services. You say that these are billable codes. The Plan denied your request. The Plan says these services cannot be paid without a modifier.  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 88342 is a column II code to column I code 88321. This claim has not been billed with an appropriate modifier to bypass the edit. We have confirmed that code 88341 is an add-on code. While this code was billed with the appropriate primary code 88342, it cannot be paid while 88342 is denied. Based on the claim submitted, Medicare billing criteria have not been met. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (88342, 88341) provided on August 20, 2021.   We note that it appears a corrected claim was submitted directly to Maximus during the review of this case. We cannot act on or process claim corrections. Corrected claim information may be submitted directly to the Plan for further review. We are only permitted to make a decision based on the claim information reviewed by the Plan for payment. Please submit any corrections or additional claim information directly to the Plan.