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

 We decided that the Plan does not have to pay for procedure code 76705.  You asked the Plan to pay for procedure code 76705. You say that this patient had multiple exams on this date of service. The Plan denied your request. The Plan says procedure code 76705 is bundled into code 93976 billed on the same day, and you did not append a modifier that would allow for separate payment.  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 procedure code 76705 is a column II code to column I code 93976.    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 procedure code 76705.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve abutment supported crowns (D6058) for teeth # 2 and 4, custom abutments (D6057) for teeth # 2 and 4, a pontic (D6245) for tooth # 3, and a porcelain crown (D2740) for tooth # 3.

You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. You say that the dental work you had done previously were not done properly. You also say that the crowns were poorly executed and did not function, leading the crowns to have to be removed. The Plan denied your request. The Plan says 2 abutment supported crowns are covered per calendar year, and once every 5 calendar years per tooth. The Plan says that 2 custom abutments are covered per calendar year, and once every 5 calendar years per tooth. The Plan says that these frequency limits have been reached. The Plan also says that pontic and porcelain crown are not listed as covered services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the frequency limit for the abutment supported crowns and custom abutments have been reached. The record shows that the Plan paid for abutment supported crowns and custom abutments for teeth # 3 and 4 that you received on February 12, 2021. Additionally, pontic and porcelain crown are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve abutment supported crowns (D6058) for teeth # 2 and 4, custom abutments (D6057) for teeth # 2 and 4, a pontic (D6245) for tooth # 3, and a porcelain crown (D2740) for tooth # 3.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on July 24, 2020.

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 Medicare coverage criteria were not met. The Qualified Independent Contractor overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan provided specific documentation to
show only 21 drug classes had been tested and not 22, which is required to bill code G0483.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, the records show only 21 drug classes
were tested. In order for code G0483 to be paid, the records must show 22 classes. Medicare rules for coverage
of these services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing
provided to the enrollee on July 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Alprostadil for injection (J0270).  You asked the Plan to pre-approve the Alprostadil. You say that you have tried other things, but they do not work. You also say that your doctor advised this medication would be best for you. The Plan denied your request. The Plan says you intend to use Alprostadil injections on an ongoing basis, which would be considered long-term and usually self-administered.    The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Alprostadil for injection (J0270).   Benefits for the Alprostadil 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the general health panel (CPT code 80050) provided on August 2, 2021.

You asked the Plan to pay for the general health panel. You say that all of the lab tests were covered except for the general health panel. You state that the general health panel is a significant lab tests designed to identify health and abnormalities. The Plan denied your request. The Plan says this code is not payable under Medicare.

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 the general health panel have not been met. CPT code 80050 is never covered or payable per Medicare. Therefore, we decided that the Plan does not have to pay for the general health panel (CPT code 80050) provided on August 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement of nail(s) by any method(s); 6 or more (CPT code 11721) provided to the enrollee on April 28, 2021.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 11721 and 11056. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for debridement of nail(s) by any method(s); 6 or more (CPT code 11721) provided to the enrollee on April 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex device.  

You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is 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 pre-approve a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. The requested Vertiflex device is not medically necessary at this time.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the crown and core buildup for tooth #21 and #27.  You asked the Plan to pre-approve the crown and core buildup. You say that you only need two crowns on the bottom for the partial to be secured. You say that you are unable to afford the crowns and they should be approved. The Plan denied your request. The Plan says the services are not covered benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.     Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the crown and core buildup for tooth #21 and #27.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on July 14, 2021.

You asked the Plan to waive the coinsurance for DME and related supplies. You say that you cannot afford the charges and the supplies are cheap. 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 20% coinsurance for DME and related supplies. 

You received DME and related supplies on July 14, 2021. The total allowed amount is $436.57 and 20% of that is $87.31.

You have been asked to pay the total coinsurance amount of $87.31 for DME and related supplies. DME and related supplies fall within the DME and related supplies 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
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.

You asked the Plan to pre-approve Durolane. You say that the requested Durolane is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Monovisc first.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria.

The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Durolane. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of Bilateral primary osteoarthritis of the knees. The Plan requires a trial of Orthovisc and Monovisc first before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. The documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) provider on July 21, 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 test (G0482) rendered by the out-of-network (OON) provider on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection procedure you had at an outpatient hospital facility on June 17, 2021.

You asked the Plan to waive the copayment for the injection procedure. You say that you did not have surgery done in a hospital You stated that you had the injection done in the doctor's office. 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 $350 copayment for outpatient surgery at an outpatient hospital facility. 

You have been asked to pay a $350 copayment for the injection procedure. The office where you received this service is part of an outpatient hospital facility and bills as an outpatient hospital.

That is why the injection procedure falls within the outpatient surgery at an outpatient hospital facility 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 injection procedure you had at an outpatient hospital facility on June 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hydrotherapy safety bathtub.

You asked the Plan to pre-approve a hydrotherapy safety bathtub. You say that a hydrotherapy safety bathtub is medically therapeutic and was denied in haste by the Plan. The Plan denied your request. The Plan says a hydrotherapy safety bathtub is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. While it is true this type of equipment can provide therapeutic relieve for some enrollee's, this is a self-help device and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a hydrotherapy safety bathtub.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on June 9, 2020.
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 Medicare billing criteria were not met. Maximus overturned the Plans denial stating
their coder found the services billed were provided and appropriate for the enrollee. The Plan requested a
reopen and stated the issue was not the necessity of the service but how it was billed. The Plan says that this
claim denied because the provider billed this service inappropriately. The Plan states codes 80307 and G0483
should not both be billed on the same claim in the same setting. The records show the claim image that indicate
the provider billed codes 80307 and G0483 together.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case this claim was not billed for not being
medically supported but because codes 80307 and G0483 were billed together in error. A corrected claim
would be required from the provider. Therefore, we decided that the Plan does not have to pay for drug testing
provided to the enrollee on June 9, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a laparoscopy with gastric bypass and Roux-en-Y gastroenterostomy (43644).

You asked the Plan to pre-approve a laparoscopy with gastric bypass and Roux-en-Y gastroenterostomy. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says that medical necessity rules for the requested procedure have not been met.

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 a laparoscopy with gastric bypass and Roux-en-Y gastroenterostomy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has sustained a known potential complication after lap sleeve gastrectomy, which is worsened gastroesophageal reflux disease (GERD). The enrollee's symptoms are refractory to medication and are also associated with an anatomic hiatal hernia. The enrollee is unable to undergo standard anti-reflux procedures. Conversion to lap gastric bypass is a standard treatment for post sleeve gastrectomy GERD. The conversion is not for treatment of obesity, but for treatment of a complication of sleeve gastrectomy in patients who cannot undergo standard anti-reflux procedures. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a laparoscopy with gastric bypass and Roux-en-Y gastroenterostomy have been met. Therefore, we decided that the Plan has to pre-approve a laparoscopy with gastric bypass and Roux-en-Y gastroenterostomy (43644).

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the technical component of the neuromonitoring services provided on May 28, 2021.

You asked the Plan to pay for the technical component of the monitoring services. You say that this should be separately paid. The Plan denied your request. The Plan says this is not a provider type that can be paid by Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and non-physician services are included in payment to the facility during an inpatient hospital stay. 

The technical components of these services include technician time and supplies. These are not separately paid and are included in facility payment. Therefore, we decided that the Plan does not have to pay for the technical component of the neuromonitoring services provided on May 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a triamcinolone acetonide injection (J3301) provided on July 8, 2021.

You asked the Plan to pay for a triamcinolone acetonide injection. You say that this is supported in the records. The Plan denied your request. The Plan says this is not documented.

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 J3301 is injection, triamcinolone acetonide, not otherwise specified, 10 mg. 

We find that CPT code J3301 is not supported in the medical record. Specifically, there is no documentation of triamcinolone acetonide being administered. Based on this information, we decided that Medicare rules for coverage of a triamcinolone acetonide injection have not been met. Therefore, we decided that the Plan does not have to pay for a triamcinolone acetonide injection (J3301) provided on July 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion service provided on March 2, 2021.

You asked the Plan to pay for home infusion service. 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 this code is not valid for Medicare purposes and is not payable.

The Plan must follow Medicare rules. Medicare rules say that code 99601 is not valid for Medicare purposes and is not payable. 

We looked at the file and Medicare rules. This code is not valid for Medicare purposes and is not payable. Based on this information, we decided that Medicare rules for coverage of home infusion service have not been met. Therefore, we decided that the Plan does not have to pay for home infusion service provided on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure.  You asked the Plan to pre-approve Intracept. You say that significant clinical and diagnostic patient-specific data supports the medical necessity of Intracept. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Intracept is unproven with insufficient evidence of efficacy.  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 Intracept. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Intracept is an experimental procedure.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ondansetron tablet, 8mg.  You asked the Plan to pre-approve Ondansetron. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is not being administered within 2 hours of chemotherapy. The Plan says that the requested drug is not being used as a full therapeutic replacement for intravenous anti-emetic therapy that would be administered at the time of cancer chemotherapy treatment. The Plan says that this drug is considered self-administered. The Plan also says the requested drug is not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron tablet, 8mg.