Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this does not meet the requirements for approval.

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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation on physical examination of tenderness to the SI joint and no mention of SI provocative testing being completed with positive findings.

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventative procedure (D1999) provided on April 14, 2021.

You asked the Plan to pay for the unspecified preventative procedure. You say that you had a very difficult time finding an in-network provider and have contacted the Plan several times regarding this issue. You feel these services should be covered as in-network services because there are no in-network dental providers that are accessible to you. The Plan denied your request. The Plan says they have agreed to cover the cleaning, exam and x-rays as in-network services due to your difficulty with finding an accessible in-network provider; however, an unspecified preventative procedure is not covered by your dental benefit, regardless of the network status of the provider.

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 unspecified preventative procedure is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified preventative procedure (D1999) provided on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on December 22, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the service is not covered under 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.

We looked at the file and the rules. The records show that the labs may have been ordered by an unsolicited outreach telephone call to the enrollee. There is no documentation to show that this request was initiated by the enrollee or the enrollee's treating physician. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on December 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service (A0428) provided on April 5, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $250 copayment for each one-way Medicare-covered ground ambulance trip. 

You have been asked to pay a $250 copayment for the one-way Medicare-covered ground ambulance trip provided. 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 ambulance service (A0428) provided on April 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the pelvis (72192)

You asked the Plan to pay for the CT scan of the pelvis. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code as required by 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, we have confirmed that 72192 has a bundled relationship with code 74177 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 of the pelvis (72192)
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five (5) additional home PT visits.
You asked the Plan to pre-approve five (5) additional home PT visits. You say that the home PT visits are medically necessary. The Plan denied your request. The Plan says the clinical notes submitted do not indicate why a skilled therapist is needed at this time to oversee the home exercise program, or why the enrollee has not had adequate training and education with the physical therapy visits already provided.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 five (5) additional home PT visits. Our reviewer says that additional home PT visits are not medically necessary. Our physician reviewer found based on the documentation provided, it is my opinion that the health Plan's denial should be upheld. The enrollee does not have documented skilled therapy needs. The enrollee appears to be functioning at a level that would allow for therapy services at a lower level of care (i.e., home exercise program, outpatient therapy). As such, the requested, ongoing, home PT services are not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of five (5) additional home PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve five (5) additional home PT visits
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an outpatient neurology visit provided on February 25, 2021.

You asked the Plan to pay for the outpatient neurology visit. You say that the service was medically necessary during an emergency room visit. The Plan denied your request. The Plan says that no prior authorization was obtained.

The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. 

We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. The record shows the outpatient neurology visit was provided during the emergency room visit. Therefore, we decided that the Plan has to pay for the outpatient neurology visit provided on February 25, 2021.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (CPT code G0483) provided to the enrollee on August 16, 2020.

You asked the Plan to pay for the testing. You say that the claim was filed timely. The Plan denied your request. The Plan says this service is not allowable because incorrect billing was identified for code billed on date of service August 16, 2020. The Plan states the date of service on the claim does not align with the records. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. The specimen was collected on August 14, 2020, and the Provider is billing for August 16, 2020. Therefore, we decided that the Plan does not have to pay for the drug test (CPT code G0483) provided to the enrollee on August 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing (CPT code(s): 81291, 81407, 81439 and 81479) provided to the enrollee on July 9, 2020.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Review of the file shows that the enrollee had cardiovascular risk assessment testing on July 9, 2020. The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing (CPT code(s): 81291, 81407, 81439 and 81479) provided to the enrollee on July 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, open (CPT code 49020-59) provided to the enrollee on November 6, 2020.
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 services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. CPT code 49020-59 (1 Unit) remains not supported. This code is included in Current Procedural Terminology (CPT) 43840; therefore, it cannot be separately reimbursed. The documents received do not support that the procedure or service was distinct or independent from other services performed; therefore, the use of the 59 modifier is not supported. Therefore, we decided that the Plan does not have to pay for drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, open (CPT code 49020-59) provided to the enrollee on November 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (29823) provided on March 23, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 29823 is "Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])". 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 services. Our reviewer says that the use of code 29823 is not supported by the records provided. Our reviewer found that the medical records do not include sufficient documentation to validate that an "arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])", was performed on March 23, 2021 Therefore, this procedure cannot be verified. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (29823) provided on March 23, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the back brace received on March 26, 2021.

You asked the Plan to pay for the back brace. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the item received is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

Review of the file shows that the case file submitted to Maximus is largely incomplete. The case file provided by the Plan did not include an initial authorization request, the Plan's initial denial, reconsideration request, the Plan's reconsideration determination, or any medical records used in making their decision. Maximus requested this missing documentation from the Plan without response. This means the Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the back brace received on March 26, 2021.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Latuda.
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 self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Latuda.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breath hydrogen or methane test (eg, for detection of lactase deficiency, fructose intolerance, bacterial overgrowth, or oro-cecal gastrointestinal transit) (CPT code 91065) provided on March 10, 2021.

You asked the Plan to pre-approve the service. You say that you have issues with constipation and bloating. You state you are worried about your health. You state other treatments have not helped. The Plan denied your request. The Plan says the Medicare rules have not been met.

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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the service is not covered to diagnose small bowel bacterial overgrowth. The items/services at issue in this case are not medically reasonable or 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve breath hydrogen or methane test (eg, for detection of lactase deficiency, fructose intolerance, bacterial overgrowth, or oro-cecal gastrointestinal transit) (CPT code 91065) provided on March 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for additional units of a colectomy (44140), enterectomy (44120), and wound therapy (97605) provided on February 9, 2021.
You asked the Plan to pay for an additional colectomy, enterectomy, and wound therapy. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says these services have been paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that additional units of CPT code 44140, 44120, and 97605 are not supported in the medical record. The medical record only supports 1 unit each of CPT code 44140, 44120, and 97605, which were previously billed and paid. Based on this information, we decided that Medicare rules for coverage of a colectomy, enterectomy, and wound therapy have not been met.
Therefore, we decided that the Plan does not have to pay for additional units of a colectomy (44140), enterectomy (44120), and wound therapy (97605) provided on February 9, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on June 30, 2020.
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 99291 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 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, there is no documentation of the first 30-74 minutes of critical care services spent on the enrollee. 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 critical care services rendered on June 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the extremity study (93971) provided on May 3, 2021.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $155 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility.
You have been asked to pay a $141.77 copayment for the Medicare-covered radiological diagnostic service provided. This is the Plan's allowed amount for this service, which is less than the applicable copayment. 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 adjust the copayment for the extremity study (93971) provided on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve psychotherapy services. You say that you have seen this provider for 9 years. You say that you would like to continue seeing this provider. The Plan denied your request. The Plan says these services can be provided safely within network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve psychotherapy services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the infusion services provided from April 8, 2021, to April 22, 2021.

You asked the Plan to waive the coinsurance for injection, infliximab-abda, biosimilar (Q5104) and administration (96413,96415). You say that the nurse assured you the infusions are 100% covered by insurance. The Plan denied your request. The Plan says you were charged this coinsurance correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay 20% coinsurance for injection, infliximab-abda, biosimilar (Q5104), administration (96413,96415). Injection, infliximab-abda, biosimilar (Q5104) and administration (96413,96415) fall within the Medicare Part B prescription drugs 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 coinsurance for the infusion services provided from April 8, 2021, to April 22, 2021.