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

We decided that the Plan does not have to pay for the laboratory services rendered on January 15, 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 separately payable.
The Plan must follow Medicare rules. The rules say that claims must be billed with the correct Type of Bill code. We looked at the file and Medicare rules. The file shows that the claim was billed with 14x type of bill for outpatient laboratory tests. These services are non-reportable for this type of bill. 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 laboratory services rendered on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on March 31, 2021.
You asked the Plan to pay for vision services. The Plan denied your request. The Plan says while the enrollee is a member of our Plan the enrollee must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis
services, and cases in which the Plan authorizes use of out-of-network providers.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided through the Plan's vision care provider. We looked at the file and the Plan's rules. The file shows the vision services were not provided through the Plan's vision care provider. Based on this information, we decided that the Plan's rules for coverage of vision services have not been met. Therefore, we decided that the Plan does not have to pay for vision services provided on March 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electro-acupuncture device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit for all indications.
The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is not a covered Medicare benefit. The requested device is for electro-acupuncture for auricular points. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve an electro-acupuncture device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 27, 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 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 April 27, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on June 9, 2021.
You asked the Plan to pay for these services. You say that you believe the Plan should pay for these services. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided from March 16, 2021, through April 12, 2021.
You asked the Plan to pay for acupuncture services. The Plan denied your request. The Plan says experimental or investigational services are not covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for acupuncture services provided from March 16, 2021, through April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with your primary care physician (PCP) on June 17, 2021.

You asked the Plan to waive the copayment for the PCP visit. You say that this was your annual wellness visit, so there should be no copayment. 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 PCP visits.

You have been asked to pay a $10 copayment for the PCP visit. We looked at your medical records to determine what type of exam you had on this date of service. An annual wellness exam only includes services to develop or update a personalized prevention plan based on your current health and risk factors. It does not include evaluation and treatment of specific medical conditions. The records show that in addition to reviewing your current medications, your physician evaluated you for chronic back muscle spasms and changed your prescription medication for this condition. This is not part of an annual wellness visit, so you were charged the PCP visit copayment. 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 visit you had with your primary care physician (PCP) on June 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement socket for a prosthetic leg (L5910).
You asked the Plan to pre-approve the replacement. You say that the replacement socket is necessary. The Plan denied your request. The Plan says the doctor's notes do not show that L5920 is damaged beyond repair and cannot be re-used for approved socket.
The Plan follows Medicare rules. Medicare rules say that replacement of a prosthesis or prosthetic component is covered if the treating practitioner orders a replacement device or part because irreparable wear of the device or a part of the device.
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 replacement. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation indicates that notes from physician indicate that member is K2 ambulator. The documentation details need for initial prosthesis on the left and replacement socket on the right, as this is ill-fitting. Member's current right prosthetic socket, approved in January of 2020, includes a socket (L5910, Addition, endoskeletal system, below knee, alignable system). The notes do not show that this socket is damaged beyond repair and cannot be re-used for approved socket. The review has determined that the medical records do not indicate need for the new socket with the new prosthesis that was overturned at the prior level. 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 replacement have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement socket for a prosthetic leg (L5910).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Volara oscillation and lung expansion therapy system.

You asked the Plan to pre-approve the requested item. You say that the enrollee's airway clearance ability has been poor. The Plan denied your request. The Plan says there is no documentation that a device that combines both oscillation and positive airway pressure is superior to individual devices.

The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 

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 requested item. Our physician reviewer found that the enrollee has cystic fibrosis (CF), with worsening pulmonary function. The Volara device provides a combination of continuous positive expiratory pressure (CPEP), high-frequency airway oscillation, and nebulizer, via mouthpiece. CPEP has not been shown to be beneficial in CF, and the combination of these three forms of treatment in the same device has not been shown to be beneficial in the home setting. Therefore, the Volara device is not medically necessary. 

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 requested item have not been met. Therefore, we decided that the Plan does not have to pre-approve a Volara oscillation and lung expansion therapy system.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional sclerotherapy.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that venous treatments are covered when specific
criteria are met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee presents with a painful
lateral right ankle ulcer. There is no improvement with compression. She has numerous cardiovascular risk
factors and pedal pulses are not documented to be palpable. The provider describes concern for peripheral
artery disease and notes that arterial studies are pending but the results of these have not been provided in the
medical record. The presence of peripheral artery disease is a limitation in the coverage criteria. Furthermore,
varicose vein treatments cannot be considered appropriate or medically necessary without determination of
satisfactory arterial perfusion to the lower extremities. The additional sclerotherapy is therefore not reasonable
or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve additional sclerotherapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services provided on April 13, 2021 to April 17, 2021.

You asked the Plan to pay for the subsequent hospital care 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 supported by the documentation.

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 99233 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. 

We find that CPT code 99233 is not supported in the medical record. Specifically, the documentation did not include medical documentation for the dates of service April 13, 2021 to April 17, 2021 to support these services billed. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services provided on April 13, 2021 to April 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthroscopy, knee, left surgery (29874, 29877, and 29880).

You asked the Plan to pre-approve arthroscopy, knee, left surgery (29874, 29877, and 29880). You say that the requested arthroscopy, knee, left surgery (29874, 29877, and 29880) is medically necessary. The Plan denied your request. The Plan says the requested arthroscopy, knee, left surgery (29874, 29877, and 29880) 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 arthroscopy, knee, left surgery (29874, 29877, and 29880). Our reviewer says that the requested arthroscopy, knee, left surgery (29874, 29877, and 29880) is not medically necessary. Our physician reviewer found the criteria for knee arthroscopy are not met. The records show that the arthritis is too advanced in the knee. The requested knee arthroscopy is not likely to be effective and is not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of arthroscopy, knee, left surgery (29874, 29877, and 29880) have not been met. Therefore, we decided that the Plan does not have to pre-approve arthroscopy, knee, left surgery (29874, 29877, and 29880).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on August 11, 2021, and August 14, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that you had the coronavirus and pneumonia and the nurse in the emergency room was not helpful about your transportation home. 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 a $125 copayment for ambulance services. You received ambulance services on August 11, 20201, and August 14, 2021. Therefore, you are responsible to pay a $125 copayment per each service. The total amount you owe is: $250. You have been asked to pay the total copayment amount of $250 for ambulance services. Ambulance services
fall within the ambulance 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 ambulance services provided on August 11, 2021, and August 14, 2021.
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing.
You asked the Plan to pre-approve BRCA testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this testing is correct, because the enrollee's cancer was diagnosed at age 78, there is no known BRCA mutation in her family, she is not noted to be of Ashkenazi Jewish ancestry, and her family history does not meet any of the criteria.
The Plan follows Medicare rules. Medicare rules state that BRCA genetic testing may be covered for certain indications. 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 BRCA testing. Our reviewer says that the enrollee does not meet the Medicare criteria for BRCA testing. Our physician reviewer found the enrollee is an 82-year old woman with stage 4 metastatic lobular cancer of the breast. The enrollee's daughter had an unknown gynecological cancer. The enrollee's father had oral cancer. The documentation does not support that the indications for BRCA testing are met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of BRCA testing have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA genetic testing.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on April 26, 2021.
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says new
documents were submitted for this appeal and consist of images and progress notes for various dates other than
the billed date of service. Duplicates of records previously reviewed were also submitted.
The Plan must follow Medicare rules. Medicare rules say that when therapy services are billed as incident to a
physician/NPP services, the requirement for direct supervision by the physician/NPP and other incident to
requirements must be met, even though the service is provided by a licensed therapist who may perform the
services unsupervised in other settings.
We looked at the file and Medicare rules. Medicare says when therapy services are billed as incident to a
physician/NPP services, the requirement for direct supervision by the physician/NPP and other incident to
requirements must be met, even though the service is provided by a licensed therapist who may perform the
services unsupervised in other settings. Therefore, we decided that the Plan does not have to pay for physical
therapy services provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the deductible for otolaryngology services you received at an out-of-network outpatient hospital clinic on July 7, 2021.
You asked the Plan to reduce the deductible for the out-of-network outpatient hospital clinic services. You say that there should be a contractual agreement with the Plan for a lower cost for you. The Plan denied your request. The Plan says you had not yet met your deductible at the time of these services, so you were charged this amount correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 copayment which applies to all medical services except for in-network services, ambulance, emergency care, and urgent care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 copayment which applies to all medical services except for in-network services, ambulance, emergency care, and urgent care. This cost sharing is a contractual obligation that had not been met at the time the out-of-network outpatient hospital clinic services were received on July 7, 2021.
Therefore, we decided that the Plan does not have to reduce the deductible for otolaryngology services you received at an out-of-network outpatient hospital clinic on July 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements were not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee was prescribed the requested drug for the prevention of febrile neutropenia in an enrollee with Neoplasm of unspecified behavior of digestive system. The provided records do not contain any information about the planned chemotherapy. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Neulasta for the enrollee.