Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for dental services provided from January 9, 2020, to October 8, 2020.
You asked the Plan to pay for these services. You say that these dental services are listed as covered by the Plan. The Plan denied your request. The Plan says you used a provider who has opted out of Medicare and is not a Plan provider. We overturned the Plans denial stating the opt out rules do not apply to supplemental benefits because the dental services provided are not covered by Medicare. The Plan requested a reopen and stated the opt out rules apply.
We agree with the Plan that these services are not covered however we do not agree with the application of the opt out rules. In order for the opt out rules to apply to supplemental benefits, the dental section of the Evidence of Coverage must also state that within that section that enrollees must use Medicare eligible providers. The Plan contract says that "Medicare-covered comprehensive dental services are covered only following reconstruction of the jaw, accidental injury, or extractions in preparation for radiation treatment."
All other services listed in the Plan contract are covered supplementally by the Plan, but there is no specific statement that enrollees must use Medicare eligible dental providers. However, the Plan contract does state that enrollees must use providers enrolled in a specific dental group and that prior authorization rules may apply. We do not show the provider used is within the Plans required dental group nor did you have prior authorization. Therefore, we decided that the Plan does not have to pay for dental services provided from January 9, 2020, to October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services provided on February 24, 2021 by an out-of-network (OON) provider.  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 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 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 anesthesia services provided on February 24, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a diagnostic colonoscopy for the enrollee.
You asked the Plan to provide coverage for a diagnostic colonoscopy. You say that this testing is required for surveillance. The Plan denied your request. The Plan says the current consensus of the American gastroenterological professional societies published recommendation reference is a 7-to-10-year recommendation after a polypectomy. Maximus overturned the Plans denial based on Local Coverage Determination (LCD): Colonoscopy and Sigmoidoscopy-Diagnostic (L34614). The Plan requested a reopen and stated that the LCD applied by us is not within the jurisdiction of the State and therefore does not apply.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Diagnostic coded services used for purposes of surveillance only are not covered. Based on this information, medical necessity was not established at the time of the appeal. Therefore, we decided that the Plan does not have to pre-approve a diagnostic colonoscopy for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that daily physical and occupational therapy is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services provided from September 30, 2020, to October 2, 2020.
You asked the Plan to pay for the inpatient services. The Plan denied your request. The Plan says that the documentation does not support that inpatient services were medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 inpatient services. Our physician reviewer found that the enrollee presented to the emergency room due to left-sided chest pain. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 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 inpatient services have been met. Therefore, we decided that the Plan has to pay for the inpatient hospital services provided from September 30, 2020, to October 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for umbilical hernia repair (49585), bladder wound repair (51860), suspension of the vagina (57280) and bilateral salpingo-oophorectomy with omentectomy (58954) provided on June 26, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria are not met. We partially overturned the Plans denial. The Plan requested a reopen and stated that after further review, the Plan finds code 58954 can be identified as bilateral per the code description "Bilateral salpingo-oophorectomy with omentectomy". Per physician fee schedule, code 58954 has a Bilateral Surgery Indicator of 2 which should be billed as 1 UOS on single claim line and modifier "-50" should not be used. However, the provider has billed code 58954 with 1 unit of service in one claim line and appended modifier "-50" which is incorrect per the Physician Fee Schedule. The Medicare Claim Processing Manual Chapter 23 for Fee Schedule Administration and Coding Requirements, Addendum shows "2 = 150 percent payment adjustment for bilateral procedure does not apply. RVUs are already based on the procedure being performed as a bilateral procedure. If procedure is reported with modifier -50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers with a 2 in the unit's field), base payment for both sides on the lower of (a) the total actual charges by the physician for both sides or (b) 100 percent of the fee schedule amount for a single code. (e.g., with RT and LT modifiers with a 2 in the units' field), base payment for both sides on the lower of (a) the total actual charges by the physician for both sides or (b) 100 percent of the fee schedule amount for a single code."
The RVUs are based on a bilateral procedure because: (a) the code descriptor specifically states that the procedure is bilateral; (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally; or (c) the procedure is usually performed as a bilateral procedure. Therefore, this claim cannot be paid as billed based on the clear Medicare billing guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, we have now decided based on the errors mad that this claim cannot be paid as billed. Therefore, we decided that the Plan does not have to pay for umbilical hernia repair (49585), bladder wound repair (51860), suspension of the vagina (57280) and bilateral salpingo-oophorectomy with omentectomy (58954) provided on June 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment charged for inpatient care provided from October 21, 2020, to October 26, 2020.
You asked the Plan to waive this copayment. You say that you were admitted back into the hospital within thirty days for a related procedure and should not have to pay this copayment.
The Plan denied your request. The Plan says this copayment was charged based on the claim submitted by the provider and the Plan contract agreement. We overturned the Plans denial stating the Plan did not address the 30-readmission reference in the Plan contract and your appeal. The Plan requested a reopen and provided additional information.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says that you must pay $290 per day for days 1 to 5 of an inpatient stay. The readmission language states, "In some instances, readmission within 30 days may result in continuation of benefits from the original admission, pending medical review by the Plan." The medical records show you had two spinal surgeries in early October. After rehabilitation it was necessary to admit you a third time, October 21, 2020, for closure of the wound present from the first two surgeries. While you were admitted within 30 days of the last surgery, you were not readmitted due to premature discharge. The treatment codes and diagnosis codes for the third admission are not the same as or billed the same as the prior inpatient admissions. The Plan was required to provide payment for all three admissions as separate and distinct events. In turn, you are responsible for your copayment for all three admission as separate and distinct events.
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 charged for inpatient care provided from October 21, 2020, to October 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the arthrocentesis procedure you had at an outpatient hospital facility on May 7, 2021.  You asked the Plan to waive the copayment for the arthrocentesis procedure. You say that you never left the doctor's exam room when you received this shot.  You said that no one checked your insurance to see if you would be responsible for any costs.  You stated that had you known of the cost, you would have refused treatment. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for this procedure ($242.59) 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 $295 copayment for outpatient surgery and other services at outpatient hospital facilities.   You have been asked to pay a $295 copayment for the arthrocentesis procedure. Records show that the location where you received these services is considered part of an outpatient hospital facility.  That is why the arthrocentesis procedure falls within the outpatient surgery and other services at outpatient hospital facilities benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the arthrocentesis procedure you had at an outpatient hospital facility on May 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share charged for outpatient infusion services provided from November 19, 2020, to December 10, 2020.
You asked the Plan to waive or reduce this cost share. You say that you had to have daily infusions and did not realize this treatment was going to be so costly. The Plan denied your request. The Plan says this cost share was charged based on the claims submitted by the provider and the Plan contract agreement. We overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information regarding this decision.
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 cost share for each service provided. 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 or reduce the cost share charged for outpatient infusion services provided from November 19, 2020, to December 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chemotherapy regimen with Carboplatin, Pemetrexed, and Pembrolizumab, with supportive medications.
You asked the Plan to pre-approve the requested treatment. You say that this treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. We overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a chemotherapy regimen with Carboplatin, Pemetrexed, and Pembrolizumab, with supportive medications. Our Physician Reviewer determined that the requested chemotherapeutic drug regimen was medically reasonable and necessary. The Plan argues the regimen of Carboplatin, Pemetrexed, and Pembrolizumab is only supported as an initial systemic therapy option for metastatic disease. The Plan states that a regimen of Carboplatin, Pemetrexed, and Pembrolizumab is not supported for use as either maintenance therapy or second-line therapy.
The Plan is correct in this case. The records show the enrollee has stage IV non-small cell lung cancer. There is evidence of metastatic disease in lymph nodes, the left adrenal gland, and spine. While the regimen of Carboplatin, Pemetrexed, and Pembrolizumab is indicated for the initial treatment of metastatic non-small cell lung cancer, it is not recommended by NCCN as maintenance therapy or second-line therapy.
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 treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve a chemotherapy regimen with Carboplatin, Pemetrexed, and Pembrolizumab, with supportive medications.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for drug testing services provided to the enrollee.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. We overturned the Plans denial. The Plan requested a reopen and stated that this claim denied because the provider billed this service inappropriately. The Plan stated the medical records show this service was coded incorrectly. This is a billing error on the part of the provider and the service is not reimbursable. The records provided do not include definitive laboratory results for 22 or more drug classes to support the criteria for the code billed. There was only a total of 13 drug classes counted from the laboratory results received.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and provide medical records to support the services billing. In this case, the records provided do not support definitive laboratory results for 22 or more drug classes which is how the claim was billed. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on January 13, 2020.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee 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 to the enrollee on January 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the arthroscopy services (29822 and 29826) provided on June 3, 2021.  You asked the Plan to pay for codes 29822 and 29826. You say that the medical records support the billing of codes 29822-59-LT and 29826-LT. The Plan denied your request. The Plan says the medical records do not support the billing of codes 29822-59-LT and 29826-LT.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  Medicare rules also say that providers must report services correctly. Providers must report services with the appropriate CPT code.  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 codes 29822 and 29826. Our reviewer says that the medical records do not support the billing of codes 29822-59-LT and 29826-LT. Our physician reviewer found when a structure is debrided prior to doing a repair, that debridement is considered inclusive in the repair. Therefore, code 29822 wound be inclusive to code 29826. The CPT code Manual definition of code 29826 is Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure). The operative report does not document partial acromioplasty, and therefore code 29826 cannot be verified.  Per Operative report "Attention was then turned to the subacromial space.  Because of significant bursitis, we elected to proceed with soft tissue subacromial decompression and bursectomy.  The soft tissue from the undersurface of the acromion removed. To report a code, all descriptors in the code must be documented to confirm the procedure was performed.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 29822 and 29826 have not been met. Therefore, we decided that the Plan does not have to pay for the arthroscopy services (29822 and 29826) provided on June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the LifeVest you rented from March 2, 2021, to June 4, 2021.  You asked the Plan to waive the coinsurance for the LifeVest. You say that you should not have to pay the coinsurance for these months because the LifeVest was not getting readings. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment.   You have been asked to pay 20% coinsurance for the LifeVest. The LifeVest falls within the durable medical equipment benefit category. This coinsurance applies regardless of your satisfaction with the device. 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 the LifeVest you rented from March 2, 2021, to June 4, 2021.