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

We decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transport (A0427) provided on October 8, 2020.

You asked the Plan to pay for the ground mileage and emergency ambulance transport. You say that the services were medically necessary. The Plan denied your request. The Plan says the information provided does not support medical necessity for ambulance transport.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules.

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 the ground mileage and emergency ambulance transport. Our reviewer says that the documentation did not support that the ambulance transport was medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee's presenting symptoms did not meet prudent layperson criteria for emergency care.

The documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this member on this date of service. Our reviewer also found that the documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on October 8, 2020.

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 ground mileage and emergency ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transport (A0427) provided on October 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on December 1, 2020 by an
out of network (OON) provider.

You asked the Plan to pay for the pathology services provided by an OON provider. You say that you would
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network
care.

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 pathology services provided on December 1, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from December 12, 2020, to December 13, 2020.

You asked the Plan to pay for the self-administered drugs. You say that you would like to know specifically what medical services are included in the billed amount for the dates of service in this case. You also say that you do not understand why they were denied. The Plan denied your request. The Plan says the drugs you received while you were in the hospital are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received not covered under Medicare Part B.

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 self-administered drugs provided in an outpatient setting from December 12, 2020, to December 13, 2020.

Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gym membership fee for January 2021.

You asked the Plan to pay for the gym membership fee for January 2021. You say that you have paid the fee and submitted proof of payment The Plan denied your request. The Plan says you must submit your request for reimbursement for 2021 separately from your 2020 request.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

The Plan's rules for coverage of gym benefits have not been met because you must submit your request for reimbursement for 2021 separately from your 2020 request for reimbursement. You received a full $119 reimbursement for 2020. If you want reimbursement for 2021 fees, you should submit a request to the Plan separately. Therefore, we decided that the Plan does not have to pay for the gym membership fee for January 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on February 12, 2021, by an OON
provider.
You asked the Plan to pay for office visit. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this service 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 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 February 12, 2021, by
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-preferred continuous glucose monitor.
You asked the Plan to pre-approve a non-preferred device. You say that the pharmacy is unable to obtain the plan-preferred device. The Plan denied your request. The Plan says the requested device is not a preferred monitor.
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred.
The requested continuous glucose monitor is a non-preferred brand. The Plan has preferred brands available. We found no exception that would require the Plan to pre-approve these non-preferred items. Therefore, we decided that the Plan does not have to pre-approve a non-preferred continuous glucose monitor.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient mental health services provided from May 19, 2020 to February 1, 2021.You asked the Plan to waive the copayments for the outpatient mental health services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received outpatient mental health care on the dates of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for Outpatient mental health care. We looked at the file, the Plan's contracts and Medicare rules. The file shows that you received outpatient mental health services from May 19, 2020 to February 1, 2021. You have been asked to pay a $20 copayment for each outpatient mental health care visit. The outpatient mental health services fall within the Outpatient mental health care benefit category. This means that you have been asked to pay the correct amounts 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 the outpatient mental health services provided from May 19, 2020 to February 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the massage therapy.
You asked the Plan to pre-approve the massage therapy. The Plan denied your request. The Plan says massage therapy is covered when ordered as part of physical therapy program in accord with Medicare guidelines.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown - porcelain/ceramic (D2740).
You asked the Plan to pre-approve the crown - porcelain/ceramic (D2740). You say that you cannot afford the crown. The Plan denied your request. The Plan says the requested service is not covered under your benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the crown - porcelain/ceramic (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on January 15, 2021 by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services were rendered by a non-contracted provider. The Plan also says that prior authorization was not obtained.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on January 15, 2021 by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided March 23, 2020.

You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.

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 the home health services are not supported in the medical record. Specifically, the claim did not include required coding for home health services. The claim did not include a valid type of bill. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided March 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a whole-body bone and/or joint imaging (78306) performed on January 12, 2021, and a pelvic CT scan (72194) performed on January 14, 2021.
You asked the Plan to waive the copayments for a whole-body bone and/or joint imaging and a pelvic CT scan. The enrollee said that he does not feel he should have had to pay the copayments at issue. The Plan denied your request. The Plan says the correct copayments were 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $100 copayment for Medicare-covered Nuclear Medicine and a $50 copayment for a Medicare-covered CT scan at a freestanding provider.
The enrollee has been asked to pay a $100 copayment for a whole-body bone and/or joint imaging and a $50 copayment for a pelvic CT scan. A whole-body bone and/or joint imaging and a pelvic CT scan fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for a whole-body bone and/or joint imaging (78306) performed on January 12, 2021, and a pelvic CT scan (72194) performed on January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.You asked the Plan to pre-approve a power wheelchair. You say that you have an unsteady gait and pain. The Plan denied your request. The Plan says you are ambulatory for short distances without support, and long distances with a rollator.The Plan follows Medicare rules.Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a power wheelchair. Our physician reviewer found that the documentation indicates that you have a mobility deficit,but it is not clear that it impairs participation in MRADLs. Your mobility deficit is helped by a walker. You have visual and hearing deficits;therefore,it is not clear that you have the ability to safely operate a PMD in the home. The documentation does not support that this request will significantly improve your ability to participate in MRADLs in the home.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the 20% coinsurance charged for Medicare Part B drugs provided on April 11, 2020.You asked the Plan to waive or reduce this coinsurance. You say that you do not believe the cost of this medication is correct.The Plan denied your request. The Plan says this coinsurance was charged based on the Medicare allowable rate for these drugs and the Plan contract agreement. 
Maximus partially overturned the Plans denial and instructed a reduced rate. The Plan requested a reopen and stated that Maximus did not apply the correct calculations based on the Medicare allowable rate. The Plan provided additional information regarding this calculation. The Plan says that the allowed amount showing on the Explanation of Benefits is not correct. The Plan provided a breakdown of the charges to show the correct amounts billed. The Plan notes the sequestration (2%) is taken off the payment (which is after cost share is assessed). The Plan states the following breakdown as well as the provider Explanation of Payment which shows the correct allowed amounts was not included in the original case file sent to Maximus. Date of Service  Code   Billed Amount  Medicare Allowed   Member Liability    Sequestration   Paid Amount
04/11/2020       A9555  $1600.00         $640.00                  $128.00                 $10.24            $501.76
04/11/2020       J2785   $360.00           $216.00                  $43.20                   $3.46             $169.34 _______________________________________________________________________________________
Total                           $1960.00         $856.00                   $171.20                $13.70            $671.10 

The Plan notes that the 2% sequestration is figured by the Medicare allowed amount minus the copayment or coinsurance and then they multiply that amount by the 2% reduction rate. For example,the Medicare allowed amount of $640.00 minus the coinsurance of $128.00 equals $512.00 multiplied by 2% equals $10.24 as the sequestration rate for this claim.Based on the new information presented by the Plan, we find they are correct in their reopen request. 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 drugs and administration. 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 or reduce the 20% coinsurance ($171.20) charged for Medicare Part B drugs provided on April 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427) received January 21, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that you had no choice but to call 911 on this date of service. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 Ambulance Services. 

You have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation 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 transportation (A0427) received January 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the enrollee can no longer check her glucose with lancets. The Plan denied your request. The Plan says the requirements for coverage have not been met.
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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 29, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that you have provided medically necessary services in good faith. In consideration for the services rendered, you are seeking reconsideration. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 laboratory services provided on May 29, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the crown (D2740) provided on October 28, 2020 by an OON provider.

You asked the Plan to pay more for the crown. You say that you would like this service to be reconsidered for coverage. The Plan denied your request. The Plan says a 50% coinsurance of the allowed amount of $677.00, which is $338.50, is covered by the Plan. The Plan also says that when services are rendered by an OON provider you will be responsible for the difference of the total amount and the allowed amount ($1,336.00 - $677.00 = $659.00).

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a 50% coinsurance of the allowed amount, plus the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay more for the crown (D2740) provided on October 28, 2020 by an OON provider.