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

 We decided that the Plan does not have to pre-approve remote electrocardiogram (EKG) monitoring.  You asked the Plan to pre-approve remote EKG monitoring. You say that without this procedure, the surgeon would not be able to get the enrollee's pacemaker implanted and set properly. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this is not supported by the medical records.  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 remote EKG monitoring. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation to support that atrial fibrillation was likely a cause of the enrollee's stroke, or that the diagnosis of atrial fibrillation as the cause of her symptoms could only be established with a mobile cardiac outpatient telemetry monitor. She has a stroke in August 2021 with subsequent percutaneous transcatheter carotid intervention, with stent placement and thrombectomy. There was no atrial fibrillation noted during monitoring in the hospital. Subsequent outpatient monitoring showed no atrial fibrillation, and a pacemaker was implanted. There is insufficient documentation to support the necessity of remote EKG monitoring in the enrollee's clinical management.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of remote EKG monitoring have not been met. Therefore, we decided that the Plan does not have to pre-approve remote electrocardiogram (EKG) monitoring.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a nuclear medicine study of bone provided on September 23, 2020.  You asked the Plan to waive the copayment for a nuclear medicine study of bone. You say that you disagree with the denied charges. 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 $270 copayment for nuclear medicine radiological services.   You have been asked to pay a $270 copayment for a nuclear medicine study of bone. A nuclear medicine study of bone falls within the outpatient diagnostic tests and therapeutic services and supplies 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 a nuclear medicine study of bone provided on September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the critical care services coded as 99291 and provided on April 3, 2021.  You asked the Plan to pay for the critical care services. You say that the documentation submitted supports the services as billed. The Plan denied your request. The Plan says the documentation does not include the time spent performing critical care services.  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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.  We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation that has been submitted does not document precisely how much time was spent performing critical care services. Without this explicit documentation, the claim cannot be processed as billed. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded as 99291 and provided on April 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a knee brace (L1851).  You asked the Plan to pre-approve knee brace. You say that the enrollee has instability. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because the records do not show that the enrollee has instability or has had recent knee surgery.  The Plan follows Medicare rules. Medicare rules state that a knee brace such as L1851 may be covered if the enrollee has had recent injury or surgery on the knee or has knee instability.  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 knee brace. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested knee orthosis. Our physician reviewer found there is no evidence of objective instability on physical examination of the knees. There is no evidence of a recent surgery or injury to the knees. The enrollee is noted to be ambulatory and there is no evidence that the requested knee brace is required.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee brace have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee brace (L1851).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Vertiflex surgery.  You asked the Plan to pre-approve Vertiflex surgery. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says there is insufficient evidence to show the efficacy of the requested procedure.  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 Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertilfex device is experimental. More research is needed to show safety and efficacy.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99215) and collection venous blood venipuncture (36415) provided on September 10, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit and collection venous blood venipuncture. You say that these services were medically reasonable and necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.  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 office visit (99215) and collection venous blood venipuncture (36415) provided on September 10, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Favorable

 We decided that the Plan has to pre-approve 6 additional physical therapy visits.  You asked the Plan to pre-approve 6 additional physical therapy visits. You say that a future course without treatment will result in a poor outcome. You say that the denial of medical services should be reconsidered so you can fully recover your range of motion and strength. The Plan denied your request. The Plan says that additional visits are 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 pre-approve 6 additional physical therapy visits. Our physician reviewer found that you had a large rotator cuff tear and had surgery. Our reviewer says that the request for an additional 6 sessions is reasonable given your condition to ensure proper instruction, review a home exercise program, and to address the remaining deficits in range of motion.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional physical therapy visits have been met. Therefore, we decided that the Plan has to pre-approve 6 additional physical therapy visits.     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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and accessory (E0673).  You asked the Plan to pay for a pneumatic compression device. You say that this equipment was medically reasonable and necessary. The Plan denied your request. The Plan says this equipment is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.    The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and accessory (E0673).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia.  You asked the Plan to pre-approve Prolia. You say that the enrollee has an intolerance to bisphosphates. The Plan denied your request. The Plan says the enrollee has not tried and failed a Zoledronic acid.   Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Prolia. Our physician reviewer found that the enrollee, with osteoporosis, did not tolerate Actonel, Boniva, or Fosamax due to gastrointestinal (GI) side effects. She does not want to try Reclast as it is in the same class. The Plan requires a trial of a Zoledronic acid before they will approve the requested drug. The provided records did not clearly describe the enrollee being intolerant to or have tried and failed injectable bisphosphonates such as zoledronic acid to support this request. There would be no expected GI-related side effects from injectable zoledronic acid. Therefore, this request for Prolia will be considered not medically necessary 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for biopsy of lymph node (38525-AS) and intraoperative identification services (38900-AS) provided on July 8, 2020.  You asked the Plan to pay for the medical services. You say that these services should be reprocessed for payment based on the documentation submitted. The Plan denied your request. The Plan says the claims have denied correctly based on Medicare rules.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules also say that assistant surgeon services are medically necessary only for certain services. If the Medicare Fee Schedule Database contains an assistant at surgery indicator of 1 for the surgical procedure in question, an assistant is not medically necessary.  In this case, code 38525 has been billed with an assistant at surgery modifier. The Medicare Fee Schedule Database confirms that an assistant at surgery is not medically necessary for this procedure and will not be paid. Furthermore, we have confirmed that code 38900 is an add-on code and the appropriate primary procedure code is not eligible for payment. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for biopsy of lymph node (38525-AS) and intraoperative identification services (38900-AS) provided on July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99204) and electrical stimulation services (G0283) provided on June 30, 2021.  You asked the Plan to pay for the office visit and electrical stimulation services. You say that you believe this claim has denied incorrectly. The Plan denied your request. The Plan says these services are neither covered by the Plan nor Medicare.  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 services at issue are not manual manipulation of the spine. The Plan has agreed to payment of the services that are manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99204) and electrical stimulation services (G0283) provided on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional routine eyewear.  You asked the Plan to pre-approve additional routine eyewear. You say that new glasses are medically necessary for you to complete daily activities. The Plan denied your request. The Plan says you have exhausted your routine eyewear benefit.  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 once every two years.  We looked at the file and the Plan's rules. The Plan provided documentation showing that routine eyewear was previously covered on April 20, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of routine eyewear has been exceeded. Therefore, we decided that the Plan does not have to pre-approve additional routine eyewear.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from September 15, 2020, through September 17, 2020, and billed with a principal diagnosis code of J15.6.  You asked the Plan to pay for the inpatient hospital care as billed. You say that the inpatient hospital care as billed is supported by the medical documentation submitted. The Plan denied your request. The Plan says the documentation does not support the principal diagnosis code as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with principal diagnosis code, J15.6, defined as pneumonia due to other gram-negative bacteria. 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 hospital care as billed. Our reviewer says that the inpatient hospital care as billed with a principal diagnosis code of J15.6. Our physician reviewer found that the documentation supported an admission for pneumonia. The enrollee with a history of chronic obstructive pulmonary disease maintained on home oxygen presented to the emergency department on September 15, 2021, with cough and dyspnea on exertion. He was treated with Rocephin and Vancomycin after cultures were ordered but no sputum culture was obtained. There was no specific clinical evidence for a gram-negative pneumonia. The review has determined that the documentation did not support the billed principal diagnosis code J15.6.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from September 15, 2020, through September 17, 2020, and billed with a principal diagnosis code of J15.6.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency department services coded as 99283 provided on May 18, 2021.  You asked the Plan to pay for the emergency department services. You say that you would like this claim reprocessed submitted based on the submitted medical documentation. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the emergency department services is a column II code to column I code 99284. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department services coded as 99283 provided on May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the moderate sedation services coded as 99153 and provided on June 3, 2021.  You asked the Plan to pay for the moderate sedation services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the claim was not billed as required by coding regulations.  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 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service).  We find that CPT code 99153 is not supported in the medical record. Specifically, this code has a Professional Component (PC)/Technical Component (TC) indicator of 3. CPT code 99153 was established as a practice expense-only code meaning there is no work component relative value units (RVU) associated with that service. The technical component will not be paid to the physician when performed in a facility setting. This means that payment for this service is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded as 99153 and provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for hearing aids provided on July 21, 2021.  You asked the Plan to pay for hearing aids. You say that you were told that you had a $3,000 benefit for hearing aids and that this provider was reimbursable. The Plan denied your request. The Plan says the denial of payment for these hearing aids is correct, because this provider is not a Plan participating hearing aid supplier.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when obtained from the Plan's hearing aid supplier.   We looked at the file and the Plan's rules. These hearing aids were not obtained from the Plan's participating hearing aid supplier. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on July 21, 2021.   Your complaint regarding receiving inaccurate information about this provider's network participation is considered to be a grievance. Maximus Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.