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

We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) provided by a network provider on October 18, 2021.

You asked the Plan to waive the copayment for the MRI. You say that you should not be responsible for the copayment because the procedure was ineffective. 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 $150 copayment for each in-network Medicare-covered service. 

You have been asked to pay a $150 copayment for the MRI. The MRI falls within "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 magnetic resonance imaging (MRI) provided by a network provider on October 18, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided on July 2, 2021.

You asked the Plan to pay for hospital services. You say that the patient was not enrolled in hospice on this date of service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for hospital services provided on July 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device.

You asked the Plan to pre-approve the Vertiflex Superion device. You say that the records provided support the need for the requested procedure. The Plan denied your request. The Plan says the requested procedure is unproven and not medically necessary due to insufficient evidence of efficacy.

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 Vertiflex Superion device. Our reviewer says that the Vertiflex Superion device is not considered medically reasonable and necessary in this case. Our physician reviewer found this requested device is considered experimental and more research is needed. 

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 Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Dara-KPD for the enrollee.
You asked the Plan to provide coverage for Dara-KPD. You say that this drug is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met. Maximus 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 Dara-KPD
(Daratumumab/Krypolis-carfilzomib/Pomalyst-pomalidomide/dexamethasone). The Maximus Physician
Reviewer determined that the drugs at issue are FDA-approved for the treatment of relapsed or refractory
multiple myeloma (in combination with pomalidomide and dexamethasone) in adults who have received at
least one prior line of therapy, including lenalidomide and a proteasome inhibitor. This patient has had two
prior lines of therapy including lenalidomide and bortezomib.
The Plan requested a reopen and argues that there is no established evidence to support the use of Dara-KPD
for the treatment of relapsed or refractory high risk multiple myeloma. The Plan notes that the Maximus
reviewer indicated that the use of Daratumumab with Pomalyst (pomalidomide) and dexamethasone is
reasonable and necessary for this member. However, the request in this case was for Kyprolis with
Daratumumab/Pomalyst/dexamethasone. The Plan agrees that Daratumumab/pomalidomide/dexamethasone
would be reasonable and necessary, but that is not the regimen that is being used as the provider is adding
Kyprolis (carfilzomib).
Our Medical Director has concluded that the Plan is correct in this case. The medical records show the enrollee
is a 66-year-old woman with a diagnosis of high-risk multiple myeloma with disease progression while on
palliative Dara-VD regimen. The request was for Pomalyst (pomalidomide), Darzalex Faspro (daratumumab;
hyaluronidase), Kyprolis (carfilzomib) and dexamethasone to treat multiple myeloma, after previous disease
progression on daratumumab. There is insufficient evidence to support the requested regimen for the treatment
of relapsed and/or refractory high risk multiple myeloma. Therefore, Medicare coverage criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Dara-KPD have not been met. Therefore, we decided that the Plan does not
have to provide coverage for Dara-KPD for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided February 8, 2021.

You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed 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. 

We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the claim form (81, lab) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided February 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammography provided on November 2, 2021.

You asked the Plan to pay for the mammography. You say that The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 did not pre-approve the services 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 a mammography provided on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on July 23, 2021.

You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says the Plan's hearing aid vendor does not accept claims for hearing aids purchased out of network and does not offer reimbursements for hearing aids or services purchased out of network.

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 provided by the Plan's hearing aid provider. 

We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on July 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided the Plan does not have to provide coverage for Ibrance for the enrollee under the Medicare Part B
benefit.
You asked the Plan to provide coverage for Ibrance under Medicare Part B. You say that Ibrance is medically
necessary for the enrollee. The Plan denied your request. The Plan says Ibrance is not one of the selfadministered
drugs covered under Medicare Part B for cancer treatment. Maximus overturned the decision
stating the drug was found to be medically necessary. The Plan requested a reopen stating the issue was not
medical necessity but the fact that this drug is not covered under Medicare Part B. The Plan noted that they do
not carry the enrollee's pharmacy or Medicare Part D benefits.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare Part B
generally does not pay for self-administered drugs.
The self-administered drug requested here are not among the types which are covered by Medicare Part B.
Therefore, we decided that the Plan does not have to provide coverage for Ibrance for the enrollee under the
Medicare Part B benefit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant
(D6010) and preventive procedure (D1999) provided on August 30, 2021.
You asked the Plan to pay for the endosteal implant and preventive procedure. The Plan denied your request.
The Plan says these services are not covered benefits under your plan. The Plan also says that the provider
submitted a prior authorization on June 8, 2021, and both you and your provider were advised that the
authorization was denied prior to the services being rendered.
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
surgical placement of implant body: endosteal implant (D6010) and preventive procedure (D1999) provided on
August 30, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for skilled nursing facility (SNF)
services provided from July 1, 2021, to July 10, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was charged based on the services provided and the Plan
contract agreement. Maximus overturned the Plans denial based on the records provided by the Plan at the time
of the appeal. The Plan requested a reopen and provided additional information regarding previous SNF stays
within the same benefit period.
Based on the additional information provided, the Plan is correct in this case. The Plan provided additional
information to show that you also were provided were skilled nursing services that began May 13, 2021, and
June 1, 2021. This treatment was also within the benefit period of services received from June 29, 2021, to July
10, 2021. Your contract with the Plan clearly says that you pay $0 copayment for days 1-20 of a skilled nursing
facility stay and a $184 copayment per day for days 21-100 for skilled nursing facility care. This means that
were asked to pay the correct amount based on your contract with the Plan and the days of SNF services
provided within one benefit period. 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 cost share charged for
skilled nursing facility (SNF) services provided from July 1, 2021, to July 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to hold you harmless for ambulance response with no transport
provided on April 17, 2021.
You asked the Plan to hold you harmless for this response. You say that an ambulance was called for
you on April 17, 2021, because you felt you were having a heart attack. Care was provided on scene, and the
paramedics told you that you did not need to go to the hospital. You accepted their recommendation as medical
professionals and did not go to the hospital, but then had to call another ambulance for transport less than an
hour later when symptoms returned. The Plan denied your request. The Plan says ambulance or emergency
response with no transport is not covered by Medicare. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare does not pay
for emergency response or ambulance services when there is no transport. The first response team called did
not provide a service that involved transport. Emergency response services without transport are not covered by
Medicare or the Plan. Therefore, we decided that the Plan does not have to hold you harmless for ambulance
response with no transport provided on April 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral sacroiliac (SI) joint fusion.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that without evidence of at least 3 provocative positive SI joint physical examination tests, the bilateral SI joint fusion would not be considered medically necessary.

The Plan must follow Medicare rules. Medicare rules say that minimally-invasive surgical fusion of the sacroiliac joint can be covered if the Medicare criteria have been met. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. There are no physical exam findings that clearly show SI joint dysfunction and pain. Percutaneous SI joint fusion is experimental. Our physician reviewer found that your condition does not meet Medicare criteria for 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral sacroiliac (SI) joint fusion.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Computed tomography (CT) scan (74176) provided on September 10, 2021.
You asked the Plan to pay for code 74176. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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. In this case, we have confirmed that code 74176 is a column II code to column I code 74177. 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 Computed tomography (CT) scan (74176) provided on September 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance waiting time (A0420), fixed wing air transport (A0430), and fixed wing air mileage (A0435) provided on April 13, 2021.
You asked the Plan to pay for the ambulance waiting time, fixed wing air transport, and fixed wing air mileage. You say that you would like this claim to be reviewed based on medical necessity and reprocessed. The Plan denied your request. The Plan says that the enrollee was not in critical condition and had stable vital signs. The Plan also says that there was no evidence of acute unstable medical conditions requiring emergent intervention.
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. 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 ambulance waiting time, fixed wing air transport, and fixed wing air mileage. Our reviewer says that these services were not medically reasonable and necessary. Our physician reviewer found the documentation did support that the patient suffered from an illness or injury that contraindicates transportation by any means other than ambulance. Our reviewer found that the documentation did not support that the patient'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 patient's survival or seriously endangered the patient's health. Our physician reviewer also found that the documentation did not support that the transferring hospital did not have adequate facilities to provide the medical services needed by the patient. 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 ambulance waiting time, fixed wing air transport, and fixed wing air mileage have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance waiting time (A0420), fixed wing air transport (A0430), and fixed wing air mileage (A0435) provided on April 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasonic guidance for needle placement (76942) billed with
a -26-modifier provided on March 2, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says this claim cannot be paid as billed. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information. The Plan stated that code 76942-26 should have been
denied as not covered. For place of service 24, the ASC payment grid the Medicare does not show code 76942
as an eligible code for payment. Also, per Encoder Pro, 76942 has an "ASC Payment Indicator - N1 which is
defined as a "packaged service or item with no separate payment allowed."
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. In this case, the Medicare
coding guidelines show code 76942 cannot be paid as billed.
Therefore, we decided that the Plan does not have to pay for ultrasonic guidance for needle placement (76942)
billed with a -26-modifier provided on March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6245) and two retainer crowns (D6740 x2).
You asked the Plan to pre-approve the pontic and retainer crowns. The Plan denied your request. The Plan says these services are not covered on your plan.
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 pre-approve a pontic (D6245) and two retainer crowns (D6740 x2).
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for services (93308 and 93325) provided on March 16, 2021.
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 were not met. Maximus overturned the Plans denial for
insufficient claim information submitted in the case file. The Plan requested a reopen and provided additional
information. The Plan states a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit
exists between codes 33361 and 93308 and 93325. A modifier indicator of "1" indicates that NCCI PTPassociated
modifiers may be used to bypass an edit under appropriate circumstances. However, an appropriate
NCCI modifier was not billed. Also, the coding rules indicate the codes 93308 and 93325 are found under
Column Two of the edit pair code 33361 found under Column One. The column two code is denied as mutually
exclusive procedures cannot be performed at the same anatomic site or the same beneficiary encounter.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say providers must report
services with the appropriate codes and modifiers. In this case, this claim cannot be paid as billed due to the
omission of the required modifier. Medicare rules for coverage were not met. Therefore, we decided the Plan
does not have to pay for physician services (93308 and 93325) provided to the enrollee on March 16, 2021.