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

We decided that the Plan does not have to pay for the emergency department (ED) services provided on March 14, 2021, billed with code 99285-25.
You asked the Plan to pay for the ED services as billed. You say that this was correctly coded and should be paid. The Plan denied your request. The Plan says the records are not sufficient to support this code.
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 99285 is Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and 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 presenting problem(s) are of high
severity and pose an immediate significant threat to life or physiologic function.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the ED services as billed. Our reviewer says
that the use of code 99285 is not supported in the medical records provided. Our reviewer found the record
indicates that the enrollee was seen in the emergency department at 3AM and subsequently discharged home.
The enrollee presented again in the afternoon because of unsteadiness of gait, altered mental status, and slurred
speech. The record provided does not indicate the presence of extensive diagnoses considered or an extensive
amount of data reviewed. The provided record does not indicate the presence of complex decision making. 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 ED services as billed have not been met. Therefore, we decided that the Plan
does not have to pay for the emergency department (ED) services provided on March 14, 2021, billed with
code 99285-25.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home blood glucose monitor (E0607).
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says in order to approve the requested supplies, there needs to be evidence supplied of a diagnosis of diabetes.
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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of a diagnosis of diabetes, which is required for this monitor. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a home blood glucose monitor (E0607).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Positron emission tomography (PET) with concurrently
acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78816).
You asked the Plan to pre-approve the PET scan. You say that in order for the enrollee to receive appropriate
diagnosis and treatment, it is your recommendation that he have an Amyvid PET scan of the brain. The Plan
denied your request. The Plan says the records do not support the medical necessity guidelines for the
requested procedure.
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found unless otherwise indicated, the exam is recommended for denial due to the lack of the
following information: the reason an Oncological PET (CPT 78811-78816) was ordered. Notes clearly show an
Amyvid (Amyloid) Brain PET (CPT 78608) is the desired study. This is according to the following portion of
ONCOLOGIC PET CMS NCDS guidelines: CMS continues to nationally cover one FDG PET study for
beneficiaries who have cancers that are biopsy proven or strongly suspected based on other diagnostic testing
when the beneficiary's treating physician determines that the FDG PET study is needed to determine the
location and/or extent of the tumor for the following therapeutic purposes related to the initial anti-tumor
treatment strategy. The review has determined that the enrollee does not have an indication for which a PET
Scan can be covered 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 the PET scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve Positron emission tomography (PET) with concurrently acquired computed tomography
(CT) for attenuation correction and anatomical localization imaging (78816).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve healthy pantry meals (S9977) and nutritional counseling (S9470) by a non-participating provider.
You asked the Plan to pre-approve healthy pantry meals and nutritional counseling. You say that you would like the Plan to reconsider coverage. The Plan denied your request. The Plan says you do not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of healthy pantry meals and nutritional counseling have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve healthy pantry meals (S9977) and nutritional counseling (S9470) by a non-participating provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from May 26, 2021,
through May 27, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you were ordered specific forms of
medication by your providers to treat your condition. You say that the denial should be reimbursed. The Plan
denied your request. The Plan says Medicare Part B does not cover self-administered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pay for the self-administered drugs
provided from May 26, 2021, through May 27, 2021.
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care (99219) provided on May 21, 2021.
You asked the Plan to pay for observation care. You say that this was requested by an in-network surgeon. The Plan denied your request. The Plan says this code is not supported by medical records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We find that CPT code 99219 is not supported in the medical record. Specifically, no medical records have been submitted that document this service. Without this information, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of observation care have not been met. Therefore, we decided that the Plan does not have to pay for observation care (99219) provided on May 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services (G0156) provided to the enrollee from January 4, 2021 to January 15, 2021.
You asked the Plan to pay for home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation did not support the services billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, insufficient records were provided to support the services billed. Therefore, we decided that the Plan does not have to pay for the home health services (G0156) provided to the enrollee from January 4, 2021 to January 15, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230) and prophylaxis - adult (D1110) provided June 7, 2021.
You asked the Plan to pay for the periodic oral exam, intraoral x-rays and dental cleaning. You say that you were not aware that the provider was no longer in-network. The Plan denied your request. The Plan says the services were provided out-of-network and therefore 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. The Plan covers the periodic oral exam, intraoral x-rays and dental cleaning when the services are rendered by a provider in the Plan's dental
network. We looked at the file, and Medicare rules. In this case the dental services were rendered by a provider who is not in the Plan's dental network. Based on this information, we decided that the Plan's rules for coverage of the periodic oral exam, intraoral x-rays and dental cleaning have not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230) and prophylaxis - adult (D1110) provided June 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray of the knee you had at an outpatient hospital facility on April 28, 2021.
You asked the Plan to waive the copayment for x-ray. You say that you do not believe that these charges are correct. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this x-ray ($99.78) is less than your copayment obligation, you are responsible for the full allowed 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 $130 copayment for x-rays in any location other than a physician's office. You have been asked to pay a $130 copayment for x-ray. You had this x-ray at an outpatient hospital facility. 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 x-ray of the knee you had at an outpatient hospital facility on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (86141, 84153, 80053, 84154) provided on June 15, 2021.
You asked the Plan to pay for the lab services. You say that services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
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 services 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 these services. Therefore, we decided that the Plan does not have to pay for lab services (86141, 84153, 80053, 84154) provided on June 15, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the hereditary cardiovascular disease testing provided on February 1, 2021, billed with codes 81407-90-XS, 81408-90-XS, and 81479-90-XS.
You asked the Plan to pay for the genetic testing as billed. You say that this was ordered by the treating physician and is medically necessary. The Plan denied your request. The Plan says that the member had genetic cardiovascular risk assessment testing on February 1, 2021. The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease.
We find that the rules cited by the Plan which indicate non-coverage are not controlling for the billing laboratory's state. Maximus was not able to find an applicable coverage rule which excludes this type of testing. In addition, the Plan's denial rationale is contradicted by the fact that some of the codes billed on this claim were approved to pay on appeal.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. The enrollee was referred for the genetic testing as billed by a contract provider. The file does not show that the Plan provided notice that the genetic testing as billed would not be covered. Under Medicare rules, this means the genetic testing as billed is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the hereditary cardiovascular disease testing provided on February 1, 2021, billed with codes 81407-90-XS, 81408-90-XS, and 81479-90-XS.
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: Transportation
Decision: Favorable

We decided that the Plan has to pay for air ambulance transportation services (A0436, A0431) at the ground transportation rate.
You asked the Plan to pay for ambulance services at a ground transportation rate. You say that you understand that the air transportation services were found to be not medically necessary after the fact, but you want to be paid for these services at the ground transportation rate per Medicare rules. The Plan denied your request. The Plan says that these services were not medically necessary. The Plan is saying a corrected claim is required but would also not be acceptable in this case.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. The rules also say that if a determination is made to order transport by air ambulance, but ground ambulance transport would have sufficed, payment for the air ambulance transport is based on the amount payable for ground ambulance transport.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for ambulance services at a ground transportation rate. Our reviewer agrees that the record does not support medical necessity for air ambulance transportation; however, ground ambulance transportation would have been appropriate in this case, and payment should be approved at the ground ambulance rate. Our physician reviewer found that the documentation does not support that the enrollee's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. The documentation does support that the transferring facility did not have adequate facilities to provide the medical services required by the enrollee, and in this case the enrollee's presenting symptoms met prudent layperson criteria for emergency care. While the criteria for air ambulance transport are not met, the criteria for ground ambulance services could be approved as medically necessary and reasonable. Ground ambulance transport would have sufficed in this case, and payment should be approved for the amount payable for ground transport. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance services at a ground transportation rate have been met. Therefore, we decided that the Plan has to pay for air ambulance transportation services (A0436, A0431) at the ground transportation rate.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), and panoramic radiographic image (D0330) provided May 12, 2021.
You asked the Plan to pay for the limited oral exam, tooth extractions and panoramic x-rays. You say that the enrollee received excellent care for necessary services and cannot afford the cost. The Plan denied your request. The Plan says these services are not covered under the enrollee's 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 pay for the
limited oral evaluation - problem focused (D0140), extraction, erupted tooth requiring removal of bone and/or
sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), and panoramic
radiographic image (D0330) provided May 12, 2021.
Your complaint about having issues getting assistance and clear information from the Plan's customer service
is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cataract surgery (66984) provided on May 18, 2021.
You asked the Plan to pay for cataract surgery. You say that you have been seeing this provider for forty years. The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for cataract surgery (66984) provided on May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99100) provided December 17, 2020.
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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 code 99100 is not supported in the medical record. Specifically, the code billed has a status indicator of "B" per the national physician fee schedule and cannot be separately paid. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided December 17, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on February 24, 2021.
You asked the Plan to pay for the physical therapy. You say that PT is medically necessary. The Plan denied
your request. The Plan says PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the physical therapy. Our reviewer says that
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found that based on review of the available records, the enrollee does not
meet Medicare coverage criteria for the physical therapy visits after February 22, 2021 when he showed good
progress attending therapy and is being educated. The documentation does not support coverage for additional
physical therapy visits. The attended therapy visits beyond the above date are 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 physical therapy have not been met. Therefore, we decided that the Plan
does not have to pay for PT provided on February 24, 2021.