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

We decided that the Plan does not have to waive the copayment for surgical services (99213, 20680) provided June 16, 2020 to August 14, 2020.
You asked the Plan to waive the copayment for the surgical services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 $295 copayment for outpatient surgery. You have been asked to pay a $885 copayment for 3 instances of outpatient surgical services at $295 each. 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 surgical services (99213, 20680) provided June 16, 2020 to August 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forautomatic blood pressure monitor (A4670) and sales tax (S9999) provided on August 5, 2020, by an out-of-network provider.You asked the Plan to pay forthe blood pressure monitor and sales tax. You say that your doctor told you that you needed to take your blood pressure once a week for sixweeks.You did not realize you would have to buy it from an in-network provider.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. Non-emergent services with non-contracted providers requireprior authorization before services being rendered. Blood pressure monitor's and tax is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension.Medicare rules say that plans can require enrollees to get care from network providers. 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.The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of thisitem in this situation.Therefore, we decided that the Plan does not have to pay forautomatic blood pressure monitor (A4670) and sales tax (S9999) provided on August 5, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse forthe oxygen concentrator (CPT Code E1390) purchased by the enrollee on June 26, 2020.You asked the Plan to reimburse forthe DME. You say that you were told the enrollee would be reimbursed for the DME.The Plan denied your request. The Plan says only rented oxygen equipment is eligible for coverage.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 rules say that only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered.Therefore, we decided that the Plan does not have to reimburse forthe oxygen concentrator (CPT Code E1390) purchased by the enrollee on June 26, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on September 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you did not know that this provider was out-of-network. The Plan denied your request. The Plan says prior 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 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 an office visit provided on September 21, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the osteogenerator stimulator provided on
August 6, 2020.
You asked the Plan to waive the coinsurance for the osteogenerator stimulator. You say that you needed the
orthotics after your surgery. You say the orthotic would have cost $614.32 without insurance, which is more
than you can afford. 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 20%
coinsurance for each Medicare-covered item.
You have been asked to pay 20% of the allowed amount for the osteogenerator stimulator. The allowed amount
is $3,008.70. ($3,008.70 x 20% = $601.74). The osteogenerator stimulator falls within the "Durable medical
equipment (DME) and related 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 coinsurance
for the osteogenerator stimulator provided on August 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe medical eye exam (92004) and diagnostic imaging of retina (92134) provided on September 25, 2020.You asked the Plan to waive the cost share forthe medical eye exam and diagnostic imaging of retina. You say that you do not want to pay for anything more than the Medicare-covered eye exam.The Plan denied your request. The Plan says the copayment applied correctly in this case.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 $75 copayment for covered diagnostic procedures and a $50 copayment for Medicare-covered eye exams.You have been asked to pay a total cost share of $98.37for the medical eye exam and diagnostic imaging of retina($50 medical eye exam copayment + $48.37 allowed amount for diagnostic service which is less than the $75 required copayment). The services providedfall within the covered diagnostic procedures and Medicare-covered eye examcategories. 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 cost share forthe medical eye exam (92004) and diagnostic imaging of retina (92134) provided on September 25, 2020
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the EKG (CPT Code 93010) provided to the enrollee on July 29, 2020, by an out-of-network provider. You asked the Plan to pay for the EKG. You say that the claim should be paid. The Plan denied your request. The Plan says this is considered as a bundled service with the emergency department visit (99285) that was billed on the same date of service by a different provider. 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 EKG have not been met. Documentation reviewed includes the EKG strip, however, there is no documentation for an interpretation by this rendering provider. Without a physician's interpretation, note, and signature, computer-generated EKG reports do not meet the requirements for the professional component of an EKG. Therefore, we decided that the Plan does not have to pay for the EKG (CPT Code 93010) provided to the enrollee on July 29, 2020, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveMRI of the thoracic spine.You asked the Planto pre-approvethe MRI. You say that this is medically necessary.The Plandenied your request. The Plansaysthere was no clinical documentation received to show medical necessity for the thoracic spine MRI.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found there is no documentation of adequate conservative measures for back pain. There are no red flags necessitating a thoracic MRI. The MRI is not medically needed at this time without adequate conservative measures.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 MRI have not been met.Therefore, we decided that the Plandoes not haveto pre-approveMRI of the thoracic spine.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation and set up of a portable x-ray (R0070 and Q0092) provided on January 8, 2020. You asked the Plan to pay for the transportation and set up of a portable x-ray. You say that you would like reconsideration because these services are payable. The Plan denied your request. The Plan says the transportation and set up is subject to consolidated billing and not separately payable by Medicare Part B. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that if the patient is in a Part A SNF stay, the transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B. We find that CPT code R0070 and Q0092 is not supported in the record. Specifically, this claim was billed with place of service code 31 indicating that the member was in a Part A SNF stay. Because the member was in a Part A SNF stay, the transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B. Based on this information, we decided that Medicare rules for coverage of the transportation and set up of a portable x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the transportation and set up of a portable x-ray (R0070 and Q0092) provided on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea maxillary partial denture (D5213).You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysa removable partial denture appears under the same policy on November 14, 2019.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. The Plan covers the services when the services are medically necessary and reasonable. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the upper partial denture was fabricated in 2019, and is less than two years old. The provider was apparently never advised that the appliance was uncomfortable. The appliance was never adjusted. There is nothing showing that the appliance is defective in any way. There is no current information provided that would indicate that the existing partial denture was not servicable. Given the recent fabrication of the appliance, and lack of information as to any defect of the appliance, a replacement partial denture would not be considered medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea maxillary partial denture (D5213).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the therapy required for the member is not therapy that is uniquely provided in an IRF.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a tibial fracture after a fall. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on August 25, 2020.You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have topay for outpatient hospital services provided on August 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe GeneSight Psychotropic test (CPT Code 81479) provided on July 22, 2020.You asked the Plan to pay forthe testing. You say that the services should be covered based on the LCD.The Plan denied your request. The Plan says this test was ordered by aboard certified family medicine physician specializing in geriatric medicine.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. This test was ordered by a board certified family medicine physician specializing in geriatric medicine. This test needs to be ordered by a licensed psychiatrist or neuropsychiatrist.Therefore, we decided that the Plan does not have to payforthe GeneSight Psychotropic test (CPT Code 81479) provided on July 22, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe additional 21 extractions and the 4 alveoloplasty provided on November 14, 2019.You asked the Plan to pay forthe 21 additional extractions. You say that the extractions were done due to poor dentition and concern that bacteremia is possibly oral source.The Plan denied your request. The Plan says 2 extractions are covered per calendar year. The Plan says that the frequency limit for this service has been exceeded. The Plan also says that alveoloplasty 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 inexcess of Medicare coverage, the frequency limit of 2 extractions per calendar year has been exceeded. The record shows that the Plan paid for 2 extractions that you received on this date of service. Additionally, the alveoloplasty are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe additional 21 extractions and the 4 alveoloplasty provided on November 14, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan does not have to waivethe $100 copayment charged for ambulance transport provided on November 15, 2019.You asked the Plan to waivethis transport. You say that you do not believe this copayment is correct.The Plan denied your request. The Plan says this copayment was charged per your 2019 Plan contract agreement. Maximus overturned the Plans denial stating the correct contract information had not been submitted. The Plan requested a reopen and provided the 2019 contract information required for review.The Plan is correct in this case. 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 $100 copayment for ambulance transport. 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 waivethe $100 copayment charged for ambulance transport provided on November 15, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation and four removals of residual tooth roots provided on July 20, 2020.You asked the Plan to pay forthe problem focused limited oral evaluation and removals of residual tooth roots. You say that these services were medically necessary. You also say that you believe these services should be covered under your medical insurance.The Plan denied your request. The Plan says these services are not covered because you did not elect to purchase supplemental dental coverage.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe problem focused limited oral evaluation and four removals of residual tooth roots provided on July 20, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Conformis custom knee implant.You asked the Plan to pre-approvethe implant. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this implant is experimental.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 implant. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found ultimate treatment outcomes utilizing this specific customized implant/protocol (as compared to standardized non-custom implant/protocols)have not been documented evidencing significant differences.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 implant have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Conformis custom knee implant
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe periodontal maintenance (D4910) provided on June 18, 2020.You asked the Plan to reimburse you forthe dental service. You say that you were billed $63 for the cleaning. You say that you thought you could have your teeth cleaned twice per year. You also say that you have a bill for $53.60 which you do not feel you should have to pay.The Plan denied your request. The Plan says periodontal maintenance 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, periodontal maintenance is not among those covered under this benefit.Therefore, we decided that the Plan does not have to reimburse you forthe periodontal maintenance (D4910) provided on June 18, 2020.