Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 14, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out of network physician services provided to the enrollee on June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81227, 81225, 81226, 81223) provided June 7, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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 81227, 81225, 81226, & 81223 are not supported in the medical record. Specifically, in this case a single lab procedure provided multiple results. A single CPT code should be billed for this service per the CMS National Correct Coding Initiative Coding Policy Manual for Medicare Services, Ch. X, Page 5. 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 (81227, 81225, 81226, 81223) provided June 7, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the anesthesia services provided on February 22, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the case file submitted to Maximus was largely 
incomplete. The case file is missing the initial denial letter and a valid explanation of why these services are 
being denied. One document in the case file says that the services are denied due to there not being a waiver of 
liability submitted; however, there was a waiver of liability submitted with the case file. This means the plan 
has not substantiated their denial. Therefore, we decided that the Plan has to pay for the anesthesia services 
provided on February 22, 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit provided on March 17, 2020. 
 
You asked the Plan to pay for an emergency department visit. You say that you are being sued for this 
physician bill when you received emergency room care. The Plan denied your request. The Plan says Medicare 
is the primary payer for the services. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an emergency department visit provided on March 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the external mobile cardiovascular telemetry with 
electrocardiographic (ECG) recording (93228 and 93229).) 
 
You asked the Plan to pre-approve the external mobile cardiovascular telemetry with electrocardiographic 
recording. You say that the service is medically necessary. The Plan denied your request. The Plan says the 
request is not medically necessary because the records do not show cardiac symptoms or abnormal cardiac 
testing. 
 
The Plan follows Medicare rules. Medicare rules say that covered uses are to: a. Detect, characterize, and 
document symptomatic transient arrhythmias; b. Initiate, revise, or discontinue arrhythmic drug therapy; or, c. 
Carry-out early post-hospital monitoring of patients discharged after myocardial infarction (MI). 
 
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 external mobile cardiovascular 
telemetry with electrocardiographic recording. Our reviewer says that the service is not medically necessary. 
Our physician reviewer found the suspicion for congestive heart failure was low and an echocardiogram was to 
be arranged. If the echocardiogram was unremarkable, a venous insufficiency evaluation would be pursued. An 
echocardiogram on August 6, 2021 demonstrated normal left ventricular ejection fraction, and no clinically 
significant valvular pathology. 
 
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 external mobile cardiovascular telemetry with electrocardiographic 
recording have not been met. Therefore, we decided that the Plan does not have to pre-approve the external 
mobile cardiovascular telemetry with electrocardiographic (ECG) recording (93228 and 93229).
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 this is medically necessary. The Plan denied your request. The Plan says the services can safely be received in other settings, for example, a skilled nursing facility, home with home health services or home with outpatient therapy.
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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform/tolerate fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the removal of existing lumbar hardware, exploring possible pseudarthrosis at L5-S1, decompression, and fusion with instrumentation at T10-L3 (22612, 22614, 22634, 22842, 22843 and 22853) for the enrollee.
You asked the Plan to pre-approve these services. You say that the member has failed conservative treatment. The Plan denied your request. The Plan says that that the imaging does not demonstrate a significant pathology that would warrant the degree of surgery recommended.
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. The records show that the patient has stenosis at at least 2 levels above her fusion including the T11 level. There is concern for failure of fusion at the single level below the fusion at L5-S1. Additional decompressive surgery only will not be successful in this case with previous fusion and multilevel stenosis. Additional decompression combined with fusion for T10-S1 levels in the most appropriate procedure based on the pathology present in the imaging studies. The decompression only surgery is likely to fail, and fusion is needed to reduce the risk of surgical failure. 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 the removal of existing lumbar hardware, exploring possible pseudarthrosis at L5-S1, decompression, and fusion with instrumentation at T10-L3 (22612, 22614, 22634, 22842, 22843 and 22853) 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oxygen concentrator (E1390), and oxygen system 
(E0431). 
 
You asked the Plan to pre-approve the oxygen concentrator and oxygen system. You say that the items are 
medically necessary. The Plan denied your request. The Plan says there is no documentation of an arterial Pao2 
at or below 55mmHG or oxygen saturation (SpO2) at or below 88% measured at rest. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient 
must have tried other alternative treatments without complete success. The patient must meet one of the
following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep; 
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
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 oxygen concentrator and oxygen 
system. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
medical records do not include oxygenation measurements on room air that meet Medicare criteria for oxygen 
needs. 
 
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 oxygen concentrator and oxygen system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the oxygen concentrator (E1390), and oxygen system 
(E0431).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the simple extractions (D7140) provided on May 20, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the extractions. You say that you were in extreme pain and an untreated bacterial infection can lead to sepsis of the body. You also say that you have no way of paying for these extractions. The Plan denied your request. The Plan says the extractions were not ordered or performed by an in-network provider. The Plan also says there is either an invalid or missing authorization.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the simple extractions (D7140) provided on May 20, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy with biopsy provided on May 5, 2021. 
 
You asked the Plan to pay for the colonoscopy with biopsy. You say that CPT code 45380 was billed with the 
XU modifier because the service does not overlap usual components of the main service. You say that the 
medical records support this CPT code and you are requesting prompt processing of the claim. The Plan denied 
your request. The Plan says the documents do not support that the procedure was distinct or independent from 
the other services performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 45380 is colonoscopy, flexible; with biopsy, single or 
multiple. 

We asked our coder 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 colonoscopy with biopsy. Our reviewer says that CPT 
45380 and CPT 45385 should only be billed together when some polys were removed, and biopsies were then 
performed in another area. Our reviewer found that the documentation does not support additional biopsies 
were performed. Our reviewer says that this does not meet criteria for CPT 45380 and CPT 45385 to be 
covered separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the colonoscopy with biopsy have not been met. Therefore, we decided that the 
Plan does not have to pay for the colonoscopy with biopsy provided on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307) rendered by the out-of-network (OON) provider on April 12, 2021.
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 drug testing (80307) rendered by the out-of-network (OON) provider on April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81227, 81226, 81223, 81225) provided May 26, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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 code 81227, 81226, 81223, & 81225 is not supported in the medical record. Specifically, in this case, multiple results were obtained from a single procedure. Only one code can be billed for this service. 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 (81227, 81226, 81223, 81225) provided May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas neoGNE-Series therapy (G0283, 99212, 96372, 97112, J3415, J1955, J3420, 97016) provided on March 9, 2021.
You asked the Plan to pay for the Sanexas neoGNE-Series therapy. You say that you would like these services reprocessed for medical necessity. The Plan denied your request. The Plan says these services are considered experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that outpatient physical therapy services and compounded drugs are only covered when the criteria listed in the Medicare rules section. Therapy Services (99212, 97112 97016, G0283) We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the
physical therapy services at issue in this case were rendered by a provider who is not licensed to provide
physical therapy in the State of Arizona. Therefore, the therapy services are not eligible for coverage.
Drug Services (J3415, J1955, J3420)
The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The
rules require that any compounded drug be billed using the not otherwise classified code J7999. As this
compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed,
the drug administration code, 96372, also cannot be paid.
Based on this information, we decided that Medicare rules for coverage of the Sanexas neoGNE-Series therapy
have not been met. Therefore, we decided that the Plan does not have to pay for the Sanexas neoGNE-Series
therapy (G0283, 99212, 96372, 97112, J3415, J1955, J3420, 97016) provided on March 9, 2021.
Appeal type: Imaging
Decision: Favorable

We decided the Plan has to pay for the chest x-ray (71046) provided to the enrollee on February 22, 2021.
You asked the Plan to pay for this chest x-ray. You say that this claim should be paid. The Plan denied your request. The Plan says that Medicare guidelines state a chest x-ray as part of a preoperative examination, in the absence of signs or symptoms is not covered under the Medicare benefit.
The Plan must follow Medicare rules. Medicare rules say chest x-rays are not covered in the absence of symptoms or signs of injury or disease. 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 this chest x-ray. Our physician reviewer found while the chest x-ray report lists "pre-operative evaluation" as the reason for the exam, the review of the records a clinical diagnosis which would qualify. The records state: "Diabetes mellitus, hypertension, peripheral neuropathy and finally Scleroderma. This last entity is known to be associated with interstitial lung disease and if present would have to be considered by any anesthesiologist in administering general sedation." While the chest x-ray report did not list any clinical diagnosis, the enrollee did have physical problems which would have mandated a pre-operative chest x-ray. 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 chest x-ray have been met. Therefore, we decided that the Plan has to pay for the radiologic examination, chest (71046) provided on February 22, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99153) provided June 24, 2020.
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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 code 99153 is not supported in the medical record. Specifically, CPT 99153 is a technical component only code, and is reported for services in the hospital setting. The claim was billed for the skilled nursing facility setting. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99153) provided June 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.