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

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 18, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you cannot afford this bill. The Plan denied your request. The Plan says you have been 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 $325 copayment for Medicare-covered ambulance services per trip. You have been asked to pay a $325 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 waive the copayment for the ambulance transport provided on January 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe definitive drug testing rendered on August 13, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code G0480 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 G0480 is definitive drug testing, 1-7 drug classes.We find that CPT code G0480 is not supported in the medical record. Specifically,there is no order or records stating exactly what tests are to be performed. 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 forthe definitive drug testing rendered on August 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral medications and insulin provided during the outpatient hospital stay from January 30, 2020 to February 1, 2020.
You asked the Plan to pay for the oral medications and insulin. You say that you had surgery. You also say that you were advised that the hospital would take care of any authorizations or clearances that were needed. The Plan denied your request. The Plan says the oral medications and insulin that you received during your outpatient hospital stay are considered "self-administered". The Plan also says self-administered drugs are not covered under your Medicare Part B coverage.
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 pay for the oral medications and insulin provided during the outpatient hospital stay from January 30, 2020 to February 1, 2020.
Benefits for the oral medications and insulin 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 pay for the DecisionDx-Melanoma testing rendered on August 27, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. Medicare rules say that DecisionDx-Melanoma testing is covered when specific criteria are met. We looked at the file and Medicare rules. There is no documentation to support that the Medicare criteria for coverage of the testing are met. 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 DecisionDx-Melanoma testing rendered on August 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair component or accessory, not otherwise specified (K0108).
You asked the Plan to pre-approve the DME. You say that you are requesting repairs for your wheelchair. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 DME have not been met. The notes from the wheelchair service provider do not show when this wheelchair was bought or who paid for it, or whether it still has a warranty. There are no notes that describe what is wrong with your wheelchair. The notes do not show that the doctor who signed the order ever saw you. There are no medical notes indicating what your health problems are and why you are using a wheelchair. You would have to meet all of the rules before this could be approved. Therefore, we decided that the Plan does not have to pre-approve wheelchair component or accessory, not otherwise specified (K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from September 7, 2018 to September 12, 2018.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this claim was paid at the out-of-network rate and should be paid at the 100% rate as the enrollee was taken there by ambulance and had no choice of provider. The Plan denied your request. The Plan says you have been 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $275 copayment per day, days 1 to 5, at an in-network inpatient hospital. The enrollee has been asked to pay a $275 copayment for three days of the inpatient hospital stay, which is less than the standard copayment amount. ($275 x 3 = $825). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The record shows this claim applied the in-network inpatient hospital care benefit.
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 copayment for the inpatient hospital stay provided from September 7, 2018 to September 12, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the outpatient diagnostic testing you
received on January 28, 2020.
You asked the Plan to adjust the copayment. You say that you should only have a $40 copayment. The Plan
denied your request. The Plan says there is a $150 copayment for these services.
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 up to a
$150 copayment for each Medicare-covered outpatient diagnostic procedure or test in an outpatient facility.
Review of the file shows that you were provided outpatient diagnostic services on January 28, 2020. Per your
contract with the Plan, there is a $150 copayment for outpatient diagnostic service at an outpatient facility. This
cost sharing is a contractual obligation that you agreed to pay when you enrolled in the Plan. However, the
Medicare allowed amount for these services was $115.71. Given that the allowed amount was less than the
$150 copayment, you have been asked to pay $115.71 for these services. 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 outpatient diagnostic testing you received on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (99203) and vertebral axis decompression (S9090) provided on February 22, 2019.
You asked the Plan to pay for a chiropractic office visit and vertebral axis decompression. You say that this was necessary for your herniated disc. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for a chiropractic office visit (99203) and vertebral axis decompression (S9090) provided on February 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on January 3, 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 the services are not separately payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe testing services rendered on November 27, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 95937, 95886, and 95907 are 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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. The definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). The definition of code 95907 is nerve conduction studies; 1-2 studies.We find that CPT codes 95937, 95886, and 95907 are not supported in the medical record. Specifically, the technical report does not include documentation of neuromuscular junction testing for each nerve to support code 95937. The technical report does not include documentation of a complete needle electromyography to support code 95886. The technical report does not includedocumentation of nerve conduction studies for 1-2 studies to support code 95907. 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 forthe testing services rendered on November 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 17, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 laboratory services provided on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs and the
administration provided on December 5, 2019.
You asked the Plan to waive the coinsurance for Medicare Part B drugs and the administration. You say that
you cannot afford 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 20%
coinsurance for Medicare Part B Prescription drugs.
You have been asked to pay $1,273.77, which is less than the 20% coinsurance for Medicare Part B drugs and
the administration. Medicare Part B drugs and the administration 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 Medicare Part B drugs and the
administration provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 26, 2019 to July 11,
2019 by an out of network (OON) provider.
You asked the Plan to pay for office services. You say that the provider mistakenly informed you that they
accepted this insurance. The Plan denied your request. The Plan says the denial of payment for these services is
correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 has network providers
available who can provide 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 medical services provided on June 26, 2019 to
July 11, 2019 by an out of network (OON) provider.
Your complaint regarding receiving inaccurate information about the network status of this provider is
considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances.
Please contact the Plan for more information about your grievance.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory tests. You say that you did not have information about the enrollee's insurance requirements, limitations, or conditions, nor did the enrollee physically attend your facility. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.
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 has network providers available who can provide 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 medical services provided on December 19, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the implant supported porcelain/ceramic crown (D6065) for tooth #29 provided on February 3, 2020. You asked the Plan to pay for the implant supported porcelain/ceramic crown. You say that a Plan representative told you that members of good standing for over 5 years are entitled to a waiver and have lost tooth protection. You also say that you are on a limited fixed income and have no choice but to continue with this procedure. The Plan denied your request. The Plan says that tooth #29 is a posterior (back) tooth. The Plan also says that your plan benefits for implant services are for anterior (front) teeth only. 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. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a copy of the applicable 2020 Evidence of Coverage for this case. We asked for this document, but it was not provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. Thus, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the implant supported porcelain/ceramic crown (D6065) for tooth #29 provided on February 3, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided February 4 to February 6, 2020.You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically necessary.The Plan denied your request. The Plan says that coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided February 4 to February 6, 2020.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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not require skilled services on a daily basis in an inpatient setting.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that from a nursing perspective, you had stable vital signs, and were treated for a urinary tract infection. There are no identifiable skilled nursing service needs. Regarding rehab services, you are wheelchair bound at baseline. You are at a moderate to max assist with bed mobility and transfers. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services provided on December 23, 2019.
You asked the Plan to pay for the physician's services. You say that you have been established with this physician for several years and you have great trust in him and his office is within walking distance from your home. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services. 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 the physician's services provided on December 23, 2019.