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

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on July 19, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that due to a very long, time consuming, frustrating, and painful experience, you feel the Plan should cover 3 cleanings and 3 exams each year. The Plan denied your request. The Plan says you had exceeded the limit of two oral exams each year.  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, you are limited to two oral exams each year. The record shows that you received problem focused limited oral evaluations (D0140) on February 11, 2021, and May 5, 2021 and your oral exams benefit had been exhausted.      Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) provided on October 27, 2021.  You asked the Plan to pay for the preventive procedure. You say that this service was rendered due to an emergency. The Plan denied your request. The Plan says this service is not covered by the 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 pay for the preventive procedure (D1999) provided on October 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.  You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the enrollee is safely able to operate a manual wheelchair.  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 requested device. Our physician reviewer found that the documentation indicates the enrollee, who has dementia, has a mobility deficit that impairs MRADLs in the home. The enrollee is not ameliorated by a walker, cane due to safety issues. The documentation does reveal the enrollee has a manual wheelchair and cannot self-propel but has a caregiver that can assist them. There is no detailed cognitive evaluation indicating that this enrollee can safely operate the requested device. The documentation does include an independent wheelchair evaluation which notes a power mobility device is not appropriate at this time as it is not clear if the enrollee has the safety awareness to operate a power mobility device. The documentation does not support that the requested device will significantly improve MRADL performance 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 requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve carboplatin.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has metastatic breast cancer. The record provided is insufficient to establish that the requested medication is being used for a medically accepted indication. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The carboplatin is therefore not reasonable or medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve carboplatin.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a screening digital breast tomosynthesis, bilateral (77063) provided on July 6, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a screening digital breast tomosynthesis, bilateral. You say that this patient was seen by the provider for an encounter for a screening mammogram for malignant neoplasm of the breast. You also say this is a separate identifiable billing service. The Plan denied your request. The Plan says this provider is not a participating Plan provider. The Plan also says that there is no prior authorization on file for the member to receive out-of-network care from this provider, and the member was not referred to this provider by a participating provider. The Plan also says that the documentation fails to indicate that the member's needs were urgent or emergent.  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 a screening digital breast tomosynthesis, bilateral (77063) provided on July 6, 2021, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on November 21, 2020.  You asked the Plan to pay for the hospital discharge day management. 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 enrollee's terminal condition.  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 the hospital discharge day management (99239) provided on November 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for advance care planning including the explanation and discussion of advance directives (CPT code 99497) provided to the enrollee on June 4, 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 Evaluation and Management (E/M) and advance care planning services can be provided on the same day. The Plan states both codes should be reported with modifier-25 added.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.   This claim line is being disallowed because the service is bundled. Procedure code 99497 has an unbundled relationship with history procedure code 99223. As per checking the claim, it was confirmed that service 99223 date of service June 4, 2021, with modifier 25 was paid on June 17, 2021, in the amount of $212.74. However, the 99497 appealed on the billed the claim did not include the modifier 25 needed to pay code. Therefore, we decided that the Plan does not have to pay for advance care planning including the explanation and discussion of advance directives (CPT code 99497) provided to the enrollee on June 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the continued care services provided in a skilled nursing facility (SNF) from August 24, 2021, to September 22, 2021.  You asked the Plan to pay for the continued care. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive daily skilled services.  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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continued care have not been met. Specifically, the file does not indicate that the enrollee received daily skilled services. Therefore, we decided that the Plan does not have to pay for the continued care services provided in a skilled nursing facility (SNF) from August 24, 2021, to September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on September 3, 2021.  You asked the Plan to pay for the dental service. You say that you did not have a complete set of radiographic images. You say that you single bitewing x-rays. You say that this should have been covered as part of your annual exam. You also say that this must have been coded wrong. The Plan denied your request. The Plan says complete series x-ray is not listed as a covered service.  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 complete series x-ray is not among those covered under this benefit. Additionally, the file shows that the Plan contacted the provider office who confirmed that the correct service was billed. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on September 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiofrequency ablation of the nerves innervating the sacroiliac joint (64625) provided on January 21, 2021.  You asked the Plan to pay for radiofrequency ablation of the nerves innervating the sacroiliac joint. You say that this was medically necessary. The Plan denied your request. The Plan says this is experimental.  The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation used for sacro-iliac joint pain is considered not medically necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency.   We looked at the file and Medicare rules. The service at Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation of the nerves innervating the sacroiliac joint have not been met. Therefore, we decided that the Plan does not have to pay for radiofrequency ablation of the nerves innervating the sacroiliac joint (64625) provided on January 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home visits for hemodialysis (99512) provided from June 16, 2021, to June 30, 2021.  You asked the Plan to pay for the home visits. You say that the treating facility received an approval to provide home dialysis on these dates of service. The Plan denied your request. The Plan says the treating provider is not Medicare certified.  The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program.     We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home visits have not been met. This provider is not part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the home visits for hemodialysis (99512) provided from June 16, 2021, to June 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on May 17, 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 procedure code 14301 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.  In this case, the CPT Code Manual definition of code 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm.  We find that CPT code 14301 is not supported in the medical record. Specifically, there is no documentation of an adjacent tissue transfer or rearrangement of any area of 30.1 sq cm to 60.0 sq cm. 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 pay for the surgical services rendered on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the electrical stimulation services provided on June 1, 2021.  You asked the Plan to pay for the services provided. You say that the claim should be processed at the in-network level. The Plan denied your request. The Plan says the code is invalid for use with Medicare.  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 97014 is Application of a modality to 1 or more areas; electrical stimulation (unattended). We find that CPT code 97014 is not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulation services provided on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supplies provided on August 2, 2021.  You asked the Plan to pay for the services provided. You say that the items were provided at your own cost. The Plan denied your request. The Plan says the codes are not valid for Medicare purposes.  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 S1015 and S8301 are not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the supplies provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for chiropractic manipulative treatment (98940) rendered from June 1, 2021, to June 18, 2021.  You asked the Plan to reduce the copayment for chiropractic manipulative treatment. You say that as a senior citizen with a fixed income, copayments cause you to delay or forgo care. You also say you have not been able to afford to access chiropractic treatment since July and you were not able to pay your electric bill when you received all the chiropractic charges for June. 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 $20 copayment for each Medicare-covered chiropractic visit for subluxation (when one or more of the bones of your spine move out of position).   You have been asked to pay a $20 copayment for each chiropractic manipulative treatment. Chiropractic manipulative treatment falls within the Chiropractic 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. Therefore, we decided that the Plan does not have to reduce the copayment for chiropractic manipulative treatment (98940) rendered from June 1, 2021, to June 18, 2021.   Your complaint about the Plan potentially not following the Medicare rules for chiropractic services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the debridements (11043 and 11046), negative pressure wound therapy (97605), and subsequent nursing facility care (99307) provided on June 21, 2021.  You asked the Plan to pay for the debridements, negative pressure wound therapy, and subsequent nursing facility care. You say that the modifier, GW, that was billed with this claim indicates that the service rendered is unrelated to the enrollee's terminal condition. 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 enrollee's terminal condition.  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 the debridements (11043 and 11046), negative pressure wound therapy (97605), and subsequent nursing facility care (99307) provided on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on March 10, 2021.  You asked the Plan to pay for the services provided. You say that the records support the services billed. The Plan denied your request. The Plan says no separate payment is made per Medicare.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. We find that CPT code 99100 is a bundled code. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on March 10, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for emergency care provided on August 30, 2021, and August 31, 2021.  You asked the Plan to waive the copayments for emergency care. You say that the emergency room misdiagnosed the enrollee which resulted in multiple trips. You feel that the enrollee should not be responsible for any of the charges related to the incident. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment per each visit for emergency care.   The enrollee received emergency care on August 30, 2021, and August 31, 2021. Therefore, you are responsible to pay a $90 copayment per each visit. The total amount they owe is: $90 (copayment) x 2 (emergency room visits) = $180.   The enrollee has been asked to pay the total copayment amount of $180 for emergency care. Emergency care falls within the emergency care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for emergency care provided on August 30, 2021, and August 31, 2021.   Your quality of care concerns will be forwarded to the appropriate Quality Improvement  Organization for review. Medicare does not permit MAXIMUS to make a decision on this type of complaint.