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

We decided that the Plan does not have to waive the copayments for a specialist visit and an MRI provided from December 15, 2020, to December 28, 2020.

You asked the Plan to waive the copayments for a specialist visit and an MRI. You say that you disagree with the charges because you have health insurance and they should cover the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for specialist services. Your contract with the Plan also clearly says that you must pay a $175 copayment for advanced imaging services. 

You received a specialist visit on December 15, 2020. Therefore, you are responsible to pay the $45 copayment. 

You received an MRI on December 28, 2020. Therefore, you are responsible to pay the $175 copayment. 

The total amount you owe is: $220. 

You have been asked to pay the total copayment amount of $220 for a specialist visit and an MRI. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for a specialist visit and an MRI provided from December 15, 2020, to December 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on August 19, 2019 by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided on August 19, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from November 11, 2019, through November 27, 2019.
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says that in order to determine if the member's foreign services are medically necessary, the payment request must include an itemized bill which lists the services that were rendered.
The Plan contract says that an itemized bill must be submitted to the Plan. We looked at the file and Medicare rules. The file does not contain an itemized bill that lists the services that were provided. Therefore, we decided that the Plan does not have to pay for an inpatient admission provided from November 11, 2019, through November 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device for the enrollee.
You asked the Plan to pre-approve these services. You say that this treatment is considered safe and effective, as supported by its clinical benefits to patients, continued medical professional adoption, and strong clinical evidence with numerous peer-reviewed studies. The Plan denied your request. The Plan says that experimental and investigational procedures are not covered by Medicare.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. Our physician reviewer found that the enrollee's condition does not meet 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 a Vertiflex Superion device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant removal provided by an out-of-network provider on October 5, 2020.

You asked the Plan to pay for the implant removal. You say that the procedure was necessary, and the claim should be reprocessed for payment at the highest level of network benefits available. The Plan denied your request. The Plan says utilization of network providers is required and authorization for out-of-network services is required.

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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the implant removal provided by an out-of-network provider on October 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you feel that the IRF will provide the help you need and you will be able to come out better. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the documentation does not support the complexity of your nursing, medical, and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you are expected to benefit from physical and/or occupational therapy, the record does not support that you require at least 3 hours of therapy per day for 5 days per week, or 15 hours over 7 consecutive days of therapy 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional PT visits.
You asked the Plan to pre-approve the additional PT visits. You say that you would like to appeal these services. The Plan denied your request. The Plan says any education or training should have occurred with the PT visits you have already had. The Plan also says that the medical documentation indicates that your home exercise program can be done without a skilled physical therapist present to watch you perform the exercises.
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 the additional PT visits. Our reviewer says that the requested additional home health services are not medically necessary. Our physician reviewer found the documentation does not support that you require additional skilled rehab services to provide treatment that is medically necessary. You do not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. Our reviewer found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Our physician reviewer also found that you have received at least 16 previous physical therapy sessions and an additional 8 sessions have been approved to ensure the teaching of a home exercise program. 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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on January 15, 2021.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you were not aware that you would owe anything when you switched plans and would not have done so if you had known. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on January 15, 2021. The total allowed amount is $1,895.35 and 20% of that is $379.07. You have been asked to pay the total coinsurance amount of $379.07 for a Medicare Part B drug. A Medicare Part B drug falls 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 a Medicare Part B drug provided on January 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor provided on November 30, 2020.
You asked the Plan to pay for the provided services. You say that you are continuing to service the enrollee's needs based on the doctor's orders. The Plan denied your request. The Plan says the medical records do not indicate the ordering of the provided system.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. We looked at the file and the rules. We find that the provided device is not supported by the medical records. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor provided on November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 4, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you did not have a visit with the provider in 2021 and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for each specialist visit. The medical records show that you had a specialist visit on January 4, 2021. Therefore, you are responsible to pay the $30 copayment. You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on January 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 15, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 15, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on August 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on November 18, 2020 by an out of network (OON) provider.

You asked the Plan to pay for genetic testing. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is out-of-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 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 genetic testing provided on November 18, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from September 23, 2020, to September 29, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you are unhappy with the care you received and feel that you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment per day for days 1-4 for inpatient hospital care. You had an inpatient hospital stay from September 23, 2020, to September 29, 2020. Therefore, you are responsible to pay a $350 (copayment) for days 1-4 (September 23, 2020, to September 26, 2020). $350 (copayment) x 4 (inpatient days) = $1,400. You have been asked to pay the total copayment amount of $1,400 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 waive the copayment for an inpatient hospital stay from September 23, 2020, to September 29, 2020.
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted procedures coded 27599 and 27899 provided on August 4, 2020.
You asked the Plan to pay for the unlisted procedures. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 27599 and 27899 are not supported in the medical record. Specifically, the operative report did not include documentation of an unlisted procedure of the femur or knee or documentation of an unlisted procedure of the leg or ankle; therefore, these codes cannot be verified. Based on this information, we decided that Medicare rules for coverage of the unlisted procedures have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted procedures coded 27599 and 27899 provided on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the electrocardiogram (93000) provided on January 5, 2021.

You asked the Plan to waive the co-payment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the co-payment 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 co-payment for Medicare covered diagnostic tests and procedures.

You have been asked to pay $14.98 for the Medicare covered diagnostic test performed. This amount is the Plan allowed amount which is less than the applicable co-payment for this service. 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 co-payment for the electrocardiogram (93000) provided on January 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.

You asked the Plan to provide a therapeutic continuous glucose monitor. You say that the enrollee needs a CGM to safely get the diabetes under control. The Plan denied your request. The Plan says criteria is not met for a CGM.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, uses insulin with at least three daily injections or requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor.