Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and sleeves
(E0673) provided to the enrollee on March 12, 2021.
You asked the Plan to pay for the pneumatic compression device and sleeves. You say that this was issued to
the enrollee for use during surgery. The Plan denied your request. The Plan says that the pneumatic
compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following
surgery.
The Plan must follow Medicare rules. The rules state that a Pneumatic Compression Device (PCD) coded as
E0675 to treat peripheral arterial disease (PAD) is not eligible for reimbursement
We looked at the file and Medicare rules. Specifically, this item is not a covered benefit of Medicare or the
Plan. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675)
and sleeves (E0673) provided to the enrollee on March 12, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine EEG provided on August 12, 2020 and
August 16, 2020.
You asked the Plan to pay for a routine EEG. 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and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 8, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for a routine EEG provided on August 12, 2020 and August 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abdominoplasty and panniculectomy.
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 abdominoplasty and panniculectomy 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 records show that you have had massive weight loss after weight loss surgery and have had stable weight for over six months. The records do not show that you are not able to walk normally or have chronic pain or ulcers by the abdominal skin fold. There is no documentation of a skin rash (intertrigal dermatitis) that has been present for at least three months and unresponsive to standard medical therapy. The provided photographs do not indicate a grade two pannus. The criteria for coverage are not met and the services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an abdominoplasty and panniculectomy.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit with a urologist (99214) and
the ultrasound (76775) provided on October 15, 2020.
You asked the Plan to waive the copayment for the office visit and ultrasound. You say that you are on a fixed
income and cannot afford these copayments. The Plan denied your request. The Plan says these claims were
processed correctly, and your cost-sharing responsibility was assessed in accordance with your contract.
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 $25
copayment for a Medicare-covered ultrasound and a $30 copayment for an office visit with a specialist.
You have been asked to pay a $25 copayment for the ultrasound and a $30 copayment with a specialist. 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 office visit with a urologist (99214) and the ultrasound
(76775) provided on October 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair glide provided I. Keating Furniture World, Inc. on April 20, 2021.
You asked the Plan to pay for a stair glide. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a stair glide provided on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99212) provided November 6,
2020.
You asked the Plan to pay for the office visit. You say that you have numerous patients that have checks issued
to the provider and it should be issued to the facility. You have been told numerous times that these checks will
be reissued to the correct payor. The Plan denied your request. The Plan says this service is not covered when
rendered by a chiropractor. Procedure code 98941 was approved with the correct copayment applied.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the outpatient office visit (99212) provided November 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle electromyography rendered on March 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 procedure code 95886 is 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 95886 is needle electromyography, each extremity, with
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study;
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List
separately in addition to code for primary procedure).
We find that CPT code 95886 is not supported in the medical record. Specifically, this is an add-on code that
was not billed with a valid primary procedure code. 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 needle electromyography rendered on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.
You asked the Plan to pre-approve a raised toilet seat. You say that because the standard toilet seat is too low your unable to use the facilities properly. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate for S. Udoinyion, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve panniculectomy.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not a treatment for obesity.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan has not substantiated their denial. The case file indicates that the plan had some form of medical records to use in their denial of this procedure. The plan mentions a "physical exam show[ing] panniculus extending below symphysis pubis and active intertriginous rash" and that the documentation states "excess skin causing rashes and skin tears for many years." These medical records were not provided to MAXIMUS for review, so the denial reason cannot be corroborated. Therefore, we decided that the Plan has to pre-approve panniculectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care rendered on May 15, 2020 to May 27, 2020.
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 billed with the incorrect place of service code.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 99 for "other place of service." This code can only be used if other POS codes not are not applicable.
In this case, the services should be billed with POS code 31 or 32 for a nursing facility. Therefore, we decided that the Plan does not have to pay for the nursing facility care rendered on May 15, 2020 to May 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the brain stem rendered on May 14, 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 rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70551 (MRI brain stem) and 70544 (magnetic resonance angiography of head without dye).
Code 70551 is a column II code with a modifier indicator of 1 when billed with column I code 70544. Code 70551 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the brain stem rendered on May 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429-QL) provided on May 16, 2020.
You asked the Plan to pay for ambulance services. You say that this was billed with the correct modifier. The Plan denied your request. The Plan says this was not billed with the correct code.
The Plan must follow Medicare rules. Medicare rules say that in the case where the beneficiary was pronounced dead after the ambulance is called but before the ambulance arrives at the scene, providers report code A0428 with modifier QL. We looked at the file and Medicare rules. The records show that the enrollee was pronounced dead after the ambulance was called, but the service at issue was not billed with code A0428. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0429-QL) provided on May 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998)
provided on June 19, 2021.
You asked the Plan to pay for the ambulance service. You say that you passed out and hit the ground. You say
that you are a heart patient, so your family called for an ambulance. You say that you were awake when they
arrived. You also say that alright and did not feel you needed to go to the emergency room. The Plan denied
your request. The Plan says the Medicare ambulance benefit is a transport benefit. The Plan says that if no
transport of a Medicare beneficiary occurs, there is no Medicare covered
service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on June 19, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no
transport (A0998) provided on June 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Sara Flex with handles and deluxe comfort standing slings (E1399).
You asked the Plan to pre-approve the item. You say that you need the sit to stand lift to help with mobility issues. The Plan denied your request. The Plan says the requested item is unable to be approved as it 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. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public 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 Sara Flex with handles and deluxe comfort standing slings (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for autologous soft tissue grafts (15769) provided March 24,
2021.
You asked the Plan to pay for the surgical services. You say that procedure code 15769-AS-59-LT was distinct
and separate. Please pay this code. The Plan denied your request. The Plan says services of an assistant
surgeon, co-surgeon, or surgical team are not covered for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1,
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current
Procedural Terminology (CPT) code 15769. The Medicare Fee Schedule Database contains a surgical indicator
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the
surgical services have not been met. Therefore, we decided that the Plan does not have to pay for autologous
soft tissue grafts (15769) provided March 24, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the secondary closure of a sternotomy and cardioversion provided on February 11, 2021, billed with 21750-58 and 92961-XU, respectively.

You asked the Plan to pay for the services as billed. You say that these should be paid and not be included in any other service. The Plan denied your request. The Plan says that 92961 was billed in the global period of code 33464. Payment for this cardioversion is included in payment for the global surgery since no modifier was used to identify it as separate.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan denied code 21750 on the claim due to missing information but did not make any argument regarding the payment of this code in the appeal review. The records clearly indicate that a secondary sternal closure was required and performed. Without any valid rationale, we find that denial of payment of this code, as billed with modifier -58, is not supported.

For code 92961, while -XU is not an appropriate code to indicate that a service is not included in the global surgical package, we find that the case file does not have sufficient evidence to support its denial. It is noted that payment for this would be included in payment for code 33464. However, the Plan provided a remittance advice which shows that payment was not made for code 33464. It cannot reasonably be argued payment is included in payment for an unpaid procedure. In addition, this service is a cardioversion, a treatment for a dysfunctional heart rhythm. This would clearly be outside of the usual treatment during this surgery's recovery and treats an underlying condition. Based on the lack of evidence of payment of the code 33464 and the fact that this would clearly be separate from the global package, we find this denial is also not supported. Therefore, we decided that the Plan has to pay for the secondary closure of a sternotomy and cardioversion provided on February 11, 2021, billed with 21750-58 and 92961-XU, respectively.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81401, 81403, 81404, 81405, 81406, 81479) provided November 20, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the records do not show that these are distinct services. The claim cannot be paid.

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 81401, 81403, 81404, 81405, 81406, & 81479 are not supported in the medical record. Specifically, CPT code 81439 appropriately describes the billed services. This type of testing cannot be billed as unbundled separate services.

Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81401, 81403, 81404, 81405, 81406, 81479) provided November 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the neck.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the data needed for management of pain can be obtained from the approved PET scan.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found there is no explanation of the need for this scan in addition to the already approved PET/CT. There is mention that you desire to make certain the neck pain is not due to a tumor. There is no abnormal neurology exam, and there are no plain film reports of the cervical spine in the records. Thus, the medical necessity of the scan has not been established in the submitted records. 

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the neck.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99337) rendered by the out-of-network (OON) provider on June 17, 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 domiciliary or rest home visit (99337) rendered by the out-of-network (OON) provider on June 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electric nerve stimulation (TENS) (E0730) provided on May 1, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the TENS device. You say that please review the supporting documentation submitted for reconsideration of payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. This device is only covered for the treatment of chronic low back pain.

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 transcutaneous electric nerve stimulation (TENS) (E0730) provided on May 1, 2021 by an out-of-network (OON) provider.