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

 We decided that the Plan does not have to pay for anesthesia services provided on December 30, 2020.  You asked the Plan to pay for anesthesia services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  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 anesthesia services provided on December 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care provided after January 28, 2022
.  
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that this care continues to be medically necessary. The Plan denied your request. The Plan says the continuation of inpatient psychiatric care is not medically reasonable and necessary.
  
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
   
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 continued inpatient psychiatric care. Our reviewer says that the requested continuation of inpatient psychiatric care is not medically reasonable and necessary. Our physician reviewer found based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of January 28, 2022, forward as this patient was not shown to be a danger to herself or others. She was not showing any delusions, auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats to safety
.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care provided after January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a periodic comprehensive preventive 
medicine reevaluation and management of an individual (99397) and an office visit (99214) rendered from 
April 27, 2021, to June 17, 2021.

You asked the Plan to waive the coinsurance for a periodic comprehensive preventive medicine reevaluation 
and management of an individual and an office visit.. You say that you should not owe for seeing your primary 
care provider (PCP). The Plan denied your request. The Plan says you were 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 40% 
coinsurance for each Medicare-covered visit with a PCP or specialist. 

You have been asked to pay a $51.80 in coinsurance, which is 40% of the allowed amount for a periodic 
comprehensive preventive medicine reevaluation and management of an individual ($129.49 allowed amount x 
40% coinsurance = $51.80). You have also been asked to pay $46.02 in coinsurance, which is 40% of the 
allowed amount for an office visit ($115.05 allowed amount x 40% coinsurance = $46.02). A periodic 
comprehensive preventive medicine reevaluation and management of an individual and an office visit 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 coinsurance for a periodic comprehensive preventive medicine reevaluation and 
management of an individual (99397) and an office visit (99214) rendered from April 27, 2021, to June 17, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for hearing aids provided on April 28, 2021.  You asked the Plan to reimburse you for hearing aids. You say that the Plan should reimburse for all types of hearing aids from any provider like in previous years. The Plan denied your request. The Plan says only Basic or Reserve level hearing aids purchased through the Plan's hearing aid provider are eligible for reimbursement from this Plan.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased through the Plan hearing aid provider.  We looked at the file and the Plan's rules. The file shows that the hearing aids were not purchased through the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on April 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the implantation of wireless pulmonary artery pressure sensor (33289).  

You asked the Plan to pre-approve the implantation of wireless pulmonary artery pressure sensor (33289). You say that you want to place the device for better control of her fluid shifts, and this would allow for daily monitoring. The Plan denied your request. The Plan says the service is not reasonable or medically necessary. The Plan also says that these devices have yet to be incorporated into the standard of care and remain investigational and experimental at this time.  

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the implantation of wireless pulmonary artery pressure sensor (33289). Our reviewer says that the CardioMEMS system would not be considered medically appropriate and necessary in this patient's clinical management.    

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 implantation of wireless pulmonary artery pressure sensor (33289) have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation of wireless pulmonary artery pressure sensor (33289).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service coded 99053 provided on August 14, 2021.  You asked the Plan to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service. 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, the CPT Code Manual definition of code 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service.   We find that CPT code 99053 is not supported in the medical record. Specifically, this code has a status indicator of "B". This means that payment for this code is always bundled into payment for other services not specified and no separate payment can be made. Based on this information, we decided that Medicare rules for coverage of the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service have not been met. Therefore, we decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service coded 99053 provided on August 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a computed tomography scan (70450) provided on March 10, 2021.  You asked the Plan to pay for a computed tomography scan. You say that multiple procedures were performed. 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. In this case, we have confirmed that code 70450 is a column II code to column I code 70496. 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 a computed tomography scan (70450) provided on March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral exam (D0120), prophylaxis (D1110), and amalgam (D2190) provided on July 12, 2021.
  
You asked the Plan to pay for the dental services. You say that you should be reimbursed for these services. You say that there was no other dentist that would see you. You say that this was an emergency. You also say that $160 is a lot of money for you. The Plan denied your request. The Plan says the periodic oral exam is not listed as a covered service. The Plan says that prophylaxis is not listed as a covered service. The Plan says that amalgam is not listed as a covered service either.
  
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 periodic oral exam, prophylaxis, and amalgam are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral exam (D0120), prophylaxis (D1110), and amalgam (D2190) provided on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99203) provided on October 15, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for an office visit. You say that you are looking for a primary doctor because your previous doctor went with a different program, and you cannot afford the yearly fee. You also say you had to go to walk in care service for medications. The Plan denied your request. The Plan says this provider is not a participating provider with the Plan. The Plan also says that the services were not referred by a network provider or rendered in a participating facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  

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 an office visit (99203) provided on October 15, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-ray services coded 74018 provided on September 2, 2021.  You asked the Plan to pay for the x-ray services. 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 74018 is a column II code to column I code 74019. 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 x-ray services coded 74018 provided on September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on August 26, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the services provided. You say that you disagree with the decision. The Plan denied your request. The Plan says prior 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 referring provider is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 26, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), scaling in presence of generalized moderate or severe gingival inflammation (D4346), gingival irrigation (D4921), therapeutic parenteral drug (D9610), and adjunctive procedure (D9999) provided on August 18, 2021.  

You asked the Plan to pay for the topical application of fluoride varnish, scaling, gingival irrigation, therapeutic parenteral drug, and adjunctive procedure. You say that the services you received were a dental exam, x-rays, and teeth cleaning. You also say that your benefits for using an out-of-network provider is for you to pay 20% and the other 80% should be reimbursed to you. The Plan denied your request. The Plan says these services are not covered
. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), scaling in presence of generalized moderate or severe gingival inflammation (D4346), gingival irrigation (D4921), therapeutic parenteral drug (D9610), and adjunctive procedure (D9999) provided on August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services coded 81206, 81292, 81301, 81295, 81298, 81317, 81321, 81162, 81191, and 81401 provided on February 8, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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 81206, 81292, 81301, 81295, 81298, 81317, 81321, 81162, 81191, and 81401 are not supported in the medical record. Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Review of the file shows that more than one code was submitted for the services rendered. This means that codes 81206, 81292, and 81301 are not payable as billed.  The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. This means codes 81295, 81298, 81317, 81321, 81162, 81191, and 81401 are not payable as billed.  Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81206, 81292, 81301, 81295, 81298, 81317, 81321, 81162, 81191, and 81401 provided on February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the four resin-based composites (D2332 x4) provided on August 24, 2021.  

You asked the Plan to pay for the resin-based composites. You say that it is not clear that there was a limit to fillings. The Plan denied your request. The Plan says the enrollee's benefit plan has a limit for how often this procedure is covered. The Plan also says that since the Plan has already processed one resin-based composite (D2332) with $0 enrollee cost for date of service August 11, 2021, the Plan cannot approve payment of four additional resin-based composites (D2332 x4) provided on August 24, 2021.  

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, restorative services (fillings) are limited to 1 per year. The record shows that the enrollee received a resin-based composite (D2332) on August 11, 2021 and their restorative services benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the four resin-based composites (D2332 x4) provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on April 7, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a domiciliary or rest home visit. You say that authorization was not obtained prior to seeing this patient since it is the nursing facility's responsibility to get authorizations for their patients. You also say that it was medically necessary for the patient to receive the treatment by this provider. The Plan denied your request. The Plan says it was determined the services were not urgent or emergent and an authorization was not requested or obtained prior to services being rendered.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on April 7, 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 insertion of stabilization device (22869 and 22870). 
 
You asked the Plan to pre-approve the insertion of stabilization device (22869 and 22870). You say that the member has failed conservative approaches to treatment including physical therapy, medications, injections and various non-sustainable treatments. You say that the procedure is medically necessary and should be approved. The Plan denied your request. The Plan says the services are 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 the insertion of stabilization device (22869 and 22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Interspinous process distraction devices are experimental and more research is needed.
   
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 insertion of stabilization device (22869 and 22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a dental bridge for teeth #8 to #11 comprised of a pontic (D6242) and retainer crowns (D6752).  

You asked the Plan to pre-approve the dental bridge. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered.  

Medicare generally does not cover dental services. The Plan follows the same rule. The Plan offers additional dental services through your Medicaid benefits.  

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Your Plan does offer additional dental benefits under Medicaid, but Maximus does not have jurisdiction with regards to Medicaid. Therefore, we decided that the Plan does not have to pre-approve a dental bridge for teeth #8 to #11 comprised of a pontic (D6242) and retainer crowns (D6752) under your Medicare benefits.