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

 We decided that the Plan does not have to waive the copayment for the diagnostic examination of esophagus using an endoscopy and an x-ray of the chest (43235, 71047) provided on June 14, 2021, and June 21, 2021.  You asked the Plan to waive the copayment for the diagnostic examination of esophagus and an x-ray of the chest. You say that the services should be covered as you were informed there would be no charges after the 5th day of your inpatient stay. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for surgical services and a $110 copayment for radiological services, specifically x-rays.  You have been asked to pay a $300 copayment for surgical services and an $80.84 copayment for an x-ray of the chest, which is less than the $110 stated in the Plan's contract. Diagnostic examinations of the esophagus and x-rays of the chest fall within the Outpatient hospital services 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 the diagnostic examination of esophagus using an endoscopy and an x-ray of the chest (43235, 71047) provided on June 14, 2021, and June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthetic agent injection procedure (64415) provided on March 1, 2021.

You asked the Plan to pay for anesthetic injection. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 64415 is inclusive to code 01630 and the record does not support the use of the -59 modifier to bypass this edit.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the record does not show that this was a distinct and separate procedure from the anesthesia service itself. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. In this case, we have confirmed that code 64415 is a column II code to column I code 01630. This claim has not been billed with an appropriate modifier to bypass the edit because the -59 modifier is not supported. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for anesthetic agent injection procedure (64415) provided on March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on July 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 office visit (99214) rendered by the out-of-network (OON) provider on July 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (29823) provided June 8, 2021.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

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 29823 is Shoulder arthroscopy, with extensive debridement. 

We find that CPT code 29823 is not supported in the medical record. Specifically, the operative report does not describe 3 or more discrete structures were debrided. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (29823) provided June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder arthroscopy coded 29822 provided on July 15, 2021.

You asked the Plan to pay for the shoulder arthroscopy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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. In this case, we have confirmed that code 29822 for the shoulder arthroscopy is a column II code to column I code 29827. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder arthroscopy coded 29822 provided on July 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for unlimited units of Ceftriaxone for the enrollee.
You asked the Plan to provide coverage for unlimited units of Ceftriaxone. The Plan denied your request. The
Plan says the requested units are not allowed by Medicare. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not appropriately review the quantity requested.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Ceftriaxone.
The Maximus Physician Reviewer determined that the enrollee was diagnosed with Lyme disease, with
symptoms present for over three years. Two grams of Ceftriaxone intravenously were prescribed and requested
for a 28-day course due to failing oral doxycycline. The Plan requested a reopen and stated the organization
determination request for a total of 9999 units was denied it is not allowed by Medicare. Our Medical Director
has concluded that the Plan is correct in this case. The correct question regarding the quantity of Ceftriaxone
doses requested was not addressed by the Maximus reviewer. This request exceeds the amounts allowed by
Medicare. The Plan approved coverage of the drug but did not approve the units requested. Therefore, this case
should have been upheld. We looked at this physician's review, the file, and Medicare rules. Based on this
information, we decided that Medicare rules for coverage of unlimited units of this drug have not been met.
Therefore, we decided that the Plan does not have to provide coverage for the requested units of Ceftriaxone.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for this surgery.
You asked the Plan to provide coverage for diastasis recti repair for the enrollee. You say that this surgery is
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did apply the
correct coverage criteria. The Plan states that per LCD L35090, correction of diastasis recti is not covered.
The Plan is correct in this case. The original Maximus reviewer did not apply the appropriate LCD for this case
in the original decision. Based on the medical records provided, the request for was diastasis recti repair after
weightlifting to improve constipation and improve lifestyle. Medicare rules say that repairing diastasis recti is
not covered. This surgery was considered cosmetic for convenience and is not covered. Therefore, we decided
that the Plan does not have to provide coverage for this surgery
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two (2) teeth extractions (D7210) provided on July 14, 2021.
You asked the Plan to pay for teeth extractions. You say that the claims should be processed under medical. The Plan denied your request. The Plan says extractions are not a covered benefit with your Plan. The Plan also says that per your plan benefits, you did not pick up the optional supplemental benefit package for comprehensive 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. Specifically, the records show that you did not pick up the optional supplemental package for comprehensive dental services. Therefore, we decided that the Plan does not have to pay for two (2) teeth extractions (D7210) provided on July 14, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states your records do not show that the services that you need can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are limited by your weight-bearing status. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam provided on August 20, 2021 by an out-of-network (OON) provider.

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 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 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 eye exam provided on August 20, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 18, 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 testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for infrared light therapy (97026) provided April 14, 2021 to May 19, 2021.

You asked the Plan to pay for infrared light therapy. You say that you are appealing the partially denied claim for your service from 04/14/21 to 05/19/21. The Plan denied your request. The Plan says infrared therapy is considered not reasonable and necessary by Medicare and is excluded from coverage.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of infrared light therapy have not been met. Therefore, we decided that the Plan does not have to pay for infrared light therapy (97026) provided April 14, 2021 to May 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an infectious agent screening (87798) provided on August 3, 2021.

You asked the Plan to pay for an infectious agent screening. You say that this is supported in the records. The Plan denied your request. The Plan says this is not a covered screening service.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, an infectious agent screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for an infectious agent screening (87798) provided on August 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 2, 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 are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, a diabetes obesity gene panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist office visits provided on April 27, 2021, and July 13, 2021.

You asked the Plan to waive the copayments for the specialist office visits. You say that you were not aware that your doctor was not in-network. 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 $55 copayment for each out-of-network specialist visit.

You have been asked to pay a $55 copayment for each specialist office visit. The total for both visits is $110. Specialist office visits fall 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 copayments for specialist office visits provided on April 27, 2021, and July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on August 25, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for lab testing. You say that you are appealing with supporting records. 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 authorization was not obtained.

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 August 25, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on June 9, 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 testing is not covered.

The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 

We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on June 9, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on July 19, 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 procedure codes 95885 and 95909 are not supported.

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 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). The definition of code 95909 is nerve conduction studies; 5-6 studies. 

We find that CPT codes 95885 and 95909 are not supported in the medical record. Specifically, there is no documentation of a limited needle electromyography to support code 95885. There is no documentation of 5-6 nerve conduction studies to support code 95909. 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 testing services rendered on July 19, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from February 9, 2021, through February 12, 2021.

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that the inpatient admission was not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from February 9, 2021, through February 12, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from
August 5, 2021, through August 11, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you cannot afford the
copayment. The Plan denied your request. The Plan says the copayment was applied 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 $325
copayment per day for days 1-5 for inpatient hospital care.

You have been asked to pay a $1625 ($325 x 5 = $1625) copayment for inpatient hospital care. The services at
issue fall within the inpatient hospital care 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 inpatient hospital care provided from August 5, 2021, through August 11, 2021.