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

We decided that the Plan does not have to pre-approve an endosteal implant (D6010) and a prefabricated abutment (D6056) provided by a participating provider.

You asked the Plan to pre-approve an endosteal implant and a prefabricated abutment. You say that you would like the Plan to approve these services. The Plan denied your request. The Plan says D6010 and D6056 are not covered dental 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an endosteal implant (D6010) and a prefabricated abutment (D6056) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342).  You asked the Plan to pre-approve periodontal scaling and root planing (D4342). The Plan denied your request. The Plan says periodontal scaling and root planing is only covered once every three years.  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, there is also a maximum benefit of periodontal scaling and root planing once per quadrant every three years. The Plan paid for the periodontal scaling and root planing in all quadrants provided on September 23, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on July 28, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab tests. You say that this testing was medically necessary. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the 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 laboratory testing provided on July 28, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the SuperPath hip replacement technique to be performed by an out-of-network (OON) provider.  

You asked the Plan to pre-approve the OON hip surgery with the SuperPath technique. You say that you are only able to get this type of procedure from the OON provider. You feel that this should be approved. The Plan denied your request. The Plan says the specific technique offered by the OON provider is not considered medically necessary. As such, the OON request is denied.  

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The provider at issue in this case is not a network provider with the Plan. 

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 OON hip surgery with the SuperPath technique. Our reviewer says that the requested surgical technique is not considered medically necessary and, as such, the referral to the OON provider is also not necessary. Our physician reviewer found the SuperPath hip replacement technique remains experimental. More research is needed to show safety and efficacy of the technique. Conventional hip replacement is reasonable and available from network providers.  

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 OON hip surgery with the SuperPath technique have not been met.   The Plan has network providers available who can provide the medically necessary hip replacement using the conventional technique. We found no exception that would require the Plan to pre-approve the OON hip surgery with the SuperPath technique. Therefore, we decided that the Plan does not have to pre-approve the SuperPath hip replacement technique to be performed by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for additional breast ultrasounds (76641) provided on August 17, 2020.  

You asked the Plan to pay for additional breast ultrasounds. You say that this was performed 3 times. The Plan denied your request. The Plan says this was previously paid.  

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.  

We find that additional units of CPT code 76641 are not supported in the medical record. The medical record only supports 1 unit of CPT code 76641, which was previously billed and paid. Based on this information, we decided that Medicare rules for coverage of additional breast ultrasounds have not been met. Therefore, we decided that the Plan does not have to pay for additional breast ultrasounds (76641) provided on August 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen concentrator.  

You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need this equipment to leave the house safely. The Plan denied your request. The Plan says duplicate equipment for the home is not covered and Medicare does not cover additional equipment for use outside of the home.  

The Plan must follow Medicare rules. The rules say equipment serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The rules say equipment is only covered for use in the home. The medical records show you have a stationary oxygen concentrator with tanks for use in the home. This equipment serves the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the breast prosthesis, mastectomy bra, without
integrated breast prosthesis form, any size, any type (L8000).
You asked the Plan to pre-approve the breast prosthesis, mastectomy bra. You say that you realize you received
a L8030 silicone breast prosthesis on 11/13/2020 but you have not received any L8000 mastectomy bras this
year. The Plan denied your request. The Plan says Medicare will only pay for one breast prosthesis per side for
the useful lifetime of the prosthesis. More than one external breast prosthesis per side will be denied as not
reasonable and necessary.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that you have L8030 provided on November 13, 2020. The useful lifetime expectancy for
silicone breast prosthesis is 2 years. L0830 serves the same purpose as the requested item. Therefore, we
decided that the Plan does not have to pre-approve the breast prosthesis, mastectomy bra, without integrated
breast prosthesis form, any size, any type (L8000).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from December 24, 2020, to December 28, 2020.

You asked the Plan to pay for the services. You say that the adjustment should be reconsidered. The Plan denied your request. The Plan says the DRG was updated in this case.

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. 

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the review indicates that the documentation available for review supported an admission for bilateral pulmonary emboli with a left lower extremity deep vein thrombosis for which an inferior vena cava (IVC) filter was placed. While acute respiratory failure with hypoxia was documented, supporting medical record documentation was incomplete regarding this diagnosis. A review of the documentation received was incomplete to reflect evidence of respiratory distress, (such as increased work of breathing, accessory muscle use or labored respirations), need for high flow supplemental oxygen, abnormal arterial or venous blood gas results or need for ventilatory assistance during this encounter to substantiate a diagnosis of acuterespiratory failure with hypoxia. The review has determined that the claim was not billed with the proper DRG and diagnosis codes. 

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 services provided to the enrollee from December 24, 2020, to December 28, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve in-network coverage for a total knee arthroplasty to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that there are in-network providers available to render the requested service.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. However, the plan's network provider is not able to provide the necessary service within a reasonable timeframe. The Plan must approve in-network coverage for the OON facility that is able to meet the enrollee's needs. Therefore, we decided that the Plan has to pre-approve in-network coverage for a total knee arthroplasty to be rendered by the out-of-network (OON) provider.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray transportation (R0070) provided on June 29, 2021.

You asked the Plan to pay for x-ray transportation. You say that this was billed correctly. The Plan denied your request. The Plan says this is not supported in the records.

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 R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen. 

We find that CPT code R0070 is not supported in the medical record. Specifically, the records do not include documentation showing that equipment and personnel were transported. Based on this information, we decided that Medicare rules for coverage of x-ray transportation have not been met. Therefore, we decided that the Plan does not have to pay for x-ray transportation (R0070) provided on June 29, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on March 17, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that this was related to post-COVID symptoms, so the copayment should be waived. The Plan denied your request. The Plan says it was only waiving copayments for primary and specialist visits for a period of time. They are not waiving copayments for any services provided in a hospital setting.

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 s $90 copayment for emergency room visits. 

You have been asked to pay s $90 copayment for the ER visit. Please note that the Plan's website explicitly states that the Plan is not waiving cost sharing for COVID-19 treatment. The website states that you will be responsible for cost sharing according to your benefit plan for COVID-19 treatment. 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 emergency room (ER) visit you had on March 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that you wear insole shoes that are specifically designed for people with your disability. 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 pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you had on August 10, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you had this same test in July, but it had to be redone because they did not test for cortisol like they were supposed to. You said that you should not have to pay a copayment for this test. 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 $10 copayment for lab services. You have been asked to pay a $10 copayment for the lab services. This copayment applies regardless of the reason for the test. 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 lab services you had on August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on April 15, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that you were advised that the Plan is covering all coronavirus expenses. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $45 copayment for specialist services.

You have been asked to pay a $45 copayment for the specialist office visit. Specialist office visits fall within the Physician/Practitioner Services Including Doctor's Office Visits benefit category. Please note that the Plan's coronavirus temporary provisions say that there is no cost share waivers in effect for coronavirus treatment. 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 a specialist office visit provided on April 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient mental health telehealth visit you had on August 3, 2021.

You asked the Plan to waive the copayment for the outpatient mental health telehealth visit. You say that you were told by the provider and by the Plan that this copayment would be waived. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that they have phone records showing that you called them to ask about copayments being waived on August 2, 2021. On that date, you were advised that the copayment waiver ended on March 31, 2021.

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 $30 copayment for outpatient mental health visits.

You have been asked to pay a $30 copayment for the outpatient mental health telehealth visit. the outpatient mental health telehealth visit falls within the outpatient mental health visits benefit category. There is no provision in your contract for a waiver of this amount. 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 outpatient mental health telehealth visit you had on August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for eyewear or waive the $25 copayment
charged for vision services provided on August 6, 2020.
You asked the Plan to pay for additional reimbursement for eyewear and waive the $25 copayment. You say
that you believe the plan should reimburse you more for this eyewear. The Plan denied your request. The Plan
says the $25 copayment charged was based on the Plan contract rules and the $93.35 reimbursement was paid
based also on the Plan contract agreement. Maximus overturned the Plans denial for insufficient information in
the case file regarding the cost breakdown. The Plan requested a reopen and provided additional information
regarding this copayment and further reimbursement for the eyewear.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay $25 copayment for vision
services.
The Plan provided an explanation of benefits showing the provider charged $316.42 for vision services and
eyewear. The benefit exclusions or non-allowed amount was $198.07. This left a balance of $118.35 that could
be covered or reimbursed by the Plan. You were paid by the Plan $93.35. The $25 copayment is your vision
services contractual copayment, which was still owed. 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 provide additional reimbursement or waive
the $25 copayment charged for vision services provided on August 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81455) provided on June 11, 2021.

You asked the Plan to pay for genetic testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. 

We looked at the file and Medicare rules. The genetic testing at issue was billed with 81455 and is not considered medically necessary. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81455) provided on June 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for angiographies (75726-XU) provided on April 13, 2021.
You asked the Plan to pay for angiographies. You say that this was billed correctly with a modifier to indicate
separate payment. The Plan denied your request. The Plan says this is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. hen a diagnostic procedure follows the surgical
procedure or non-surgical therapeutic procedure, you may consider that diagnostic procedure to be a separate
and distinct procedure as long as it occurs after the completion of the therapeutic procedure and isn't mingled
with or otherwise mixed with services that the therapeutic intervention requires. In this case, we have
confirmed that code 75726 is a column II code to column I code 37243. Although this code was billed with
modifier -XU to bypass the edit, the records do not support the use of this modifier. The record shows that the
angiographies were performed as part of the closing procedures for the primary procedure. Based on the claim
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to
pay for angiographies (75726-XU) provided on April 13, 2021.