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

 We decided that the Plan does not have to pay for the emergency department visit (CPT code 99284) provided to the enrollee on July 29, 2021.  You asked the Plan to pay for the emergency department visit. You say that the claim should be paid. The Plan denied your request. The Plan says the service 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.  Review of the file shows that the enrollee was seen in the emergency department on July 29, 2021. The submitted documentation supports one (1) unit of 99284, which was previously approved/paid. There is no additional documentation supporting an additional service which was billed and remains denied.    Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit (CPT code 99284) provided to the enrollee on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the angiography, extremity, unilateral, radiological supervision and interpretation (CPT code 75710) provided to the enrollee on June 29, 2021.  

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the 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.  

We asked our coder 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 service. Our reviewer found the documentation submitted was reviewed and does not meet criteria. The operative report describes angiography of the radial artery. This procedure would be inclusive to CPT code 37236 as per CPT guidelines this procedure "includes all angioplasty with the same vessel when performed". The Documentation does not support CPT code 75710 as a separate procedure.  

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for the angiography, extremity, unilateral, radiological supervision and interpretation (CPT code 75710) provided to the enrollee on June 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the specialist office visit provided on May 28, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered as you have already paid the copayment for the imaging. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided and is a cost-sharing for the office visit itself.  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 $20 copayment for Physician/Practitioner services, including doctor's office visits.     You have been asked to pay a $20 copayment for a specialist office visit. 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 specialist office visit provided on May 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for SNF care have not been met.  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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you do not have documented skilled nursing nor skilled therapy needs. Daily skilled services were not shown to be required to establish a maintenance program or to prevent deterioration of your condition.  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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on September 9, 2021.  You asked the Plan to waive the copayment for the office visit. You say that you would like reconsideration because you did not enroll in the PPO Plan. The Plan denied your request. The Plan says the cost share has been applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for Physician Services.   You have been asked to pay a $45 copayment for the office visit. The office visit falls within the Physician Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Please note, the Plan has indicated that your other insurance carrier has made payment for the remainder of this bill. Therefore, we decided that the Plan does not have to waive the copayment for the office visit (99213) provided on September 9, 2021.   MAXIMUS Federal Services read your letter and knows that you may have a question regarding your enrollment in the Plan.  MAXIMUS Federal Services cannot answer enrollment questions.  MAXIMUS Federal Services is sending a copy of your case file and your letter to the Kansas City CMS Regional Office, so that it can look into your enrollment question.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the comprehensive cardio panel (CPT code 81401, 81403, 81404, 81405, 81406, 81407, 81408, 81479) provided to the enrollee on December 29, 2020.  You asked the Plan to pre-approve the services. You say that the claim should be paid. The Plan denied your request. The Plan says the clinical value and effectiveness of molecular cardiovascular profile testing for risk stratification in asymptomatic individuals have NOT been demonstrated in the peer-reviewed literature.  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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient support made for this request for genetic testing. This form of testing has not been shown to lead to better overall major outcomes compared to standard testing and direct lifestyle treatments for cardiovascular disease and so this request for genetic testing 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the comprehensive cardio panel (CPT code 81401, 81403, 81404, 81405, 81406, 81407, 81408, 81479) provided to the enrollee on December 29, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Truxima.  You asked the Plan to pre-approve Truxima. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.  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 Truxima. Our reviewer says that this drug is not medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee has diffuse large B cell lymphoma. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Truxima have not been met. Therefore, we decided that the Plan does not have to pre-approve Truxima.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the eye exam (92014) and computerized ophthalmic diagnostic imaging (92134) provided on September 1, 2021.  

You asked the Plan to waive the copayment for the eye exam and computerized ophthalmic diagnostic imaging. You say that you would like reconsideration because this testing was medically necessary and should be covered. The Plan denied your request. The Plan says this copayment was applied correctly.  

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 applies a $50 copayment for Medicare covered vision services when provided out-of-network.  

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's copayment has been applied correctly. You have been asked to pay a $50 copayment for Medicare covered vision services. Therefore, we decided that the Plan does not have to waive the copayment for the eye exam (92014) and computerized ophthalmic diagnostic imaging (92134) provided on September 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 1 power mobility device.  You asked the Plan to pre-approve the group 1 power mobility device. You say that you would like reconsideration because the requested equipment is medically necessary. The Plan denied your request. The Plan says the documentation does not support that you meet Medicare coverage criteria for the requested equipment.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 group 1 power mobility device. Our reviewer says that the documentation does not reveal that your mobility deficit impairs MRADLs in the home and this mobility limitation is not ameliorated by a walker, cane, manual wheelchair. Our physician reviewer found the documentation does not  support that the requested device will significantly improve MRADL participation in the home.  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 group 1 power mobility device have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 1 power mobility device.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the occupational therapy visit provided on September 14, 2021.   

You asked the Plan to waive the copayment for the occupational therapy visit. You say that you met your maximum out-of-pocket amount and should not be charged the copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $10 copayment for occupational therapy at an in-network specialist's office.   

You have been asked to pay a $10 copayment for the occupational therapy visit. The occupational therapy visit falls within the "Outpatient rehabilitation services" benefit category. The record shows your total maximum out-of-pocket amount is $4,150.35. 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 occupational therapy visit provided on September 14, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met.  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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. It is not clear that the enrollee is functioning much below her baseline. It is not clear that skilled services are required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  The enrollee's care needs appear to be appropriate for a lower level of care.  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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head rendered on September 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 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 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 computed tomography (CT) scan of the head rendered on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab testing billed for services provided on March 22, 2021.  You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed services cannot be verified.  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 looked at the file and the rules. We find that CPT codes 80157, 80159, 80162, 80173, 80177, and 80201 are not supported in the medical record. The testing at issue is completed using a blood sample. The records provided do not indicate a blood sample was obtained by the enrollee.   Based on this information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for services provided on March 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on April 1, 2020.  You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contract providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the code is not appropriate for the service billed.  The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on April 1, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (76942) provided on July 23, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.  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 76942 is a column II code to column I code 78306. 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 services (76942) provided on July 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller harness (E2313), electronic connection (E2311).  You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan denied your request. The Plan says that there is not a medical need to control these power options through the joystick.  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 these items. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Provided records document that you have 4 out of 5 upper extremity strength and are independent with eating thus indicating you have adequate upper extremity strength and function to operate the wheelchair's power options with their own switches. Our physician reviewer found that your condition does not meet criteria for coverage of these 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 these items have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller harness (E2313), electronic connection (E2311).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for outpatient psychotherapy visits (90832) rendered from August 5, 2021, to September 15, 2021.  You asked the Plan to reduce the copayment for outpatient psychotherapy visits. You say that you were charged $75 when you should have been charged $25. The Plan denied your request. The Plan says you were charged the correct cost sharing 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 $75 copayment for outpatient hospital mental health care.     You have been asked to pay a total of $225 for three visits, which is a $75 copayment for each outpatient psychotherapy visit ($75 copayment x 3 visits = $225). Outpatient psychotherapy visits fall within the for outpatient hospital mental health care 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 reduce the copayment for outpatient psychotherapy visits (90832) rendered from August 5, 2021, to September 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for observation services provided by a participating provider on September 14, 2021.  

You asked the Plan to waive the copayment for observation services. You say that you were at the hospital for 6 hours. You say that you should not have to pay for this. The Plan denied your request. The Plan says the correct copayment has been applied.  

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 $200 copayment for outpatient hospital observation.       

You have been asked to pay a $200 copayment for observation services. The correct copayment has been applied to the services that were provided. Observation services fall within the outpatient hospital observation 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 observation services provided by a participating provider on September 14, 2021.