Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided November 11, 2020.
You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order, proof of delivery, or a delivery ticket.
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. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. In this case, there are no medical records available which would prove that the criteria for the therapeutic continuous glucose monitor have been met. 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 therapeutic continuous glucose monitor provided November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 9, 2020.

You asked the Plan to pay for the physician's services. You say that you have been seeing this eye doctor forever and you were not aware this provider is out of the network. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the Plan's network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of 
out-of-network providers.

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 physician's services provided on November 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair ramp received on July 30, 2020.
You asked the Plan to pay for the wheelchair ramp. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the item received is not a covered benefit.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for the wheelchair ramp received on July 30, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for testing provided to the enrollee on December 8, 2020.
You asked the Plan to pay for this testing. You say that this claim should be covered by the Plan. The Plan denied your request. The Plan says that Medicare billing criteria were not met because this testing was provided by an ineligible provider. Maximus upheld the Plans denial. After looking at this information again, Maximus reopened the case and has now found in favor of payment of this claim.
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. Opt-out rules are only available to providers that are considered physicians by Medicare rules. Facilities or labs are not subject to opting out. Also, the Plan has not provided any evidence to indicate the lab in question is not Medicare certified. The Plan has not substantiated its denial. Therefore, we have now decided the Plan is required to pay for targeted genomic sequence analysis testing provided to the enrollee on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special treatment procedure (77470) provided on November 30, 2020, through December 2, 2020.
You asked the Plan to pay for the special treatment procedure. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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. In this case, the CPT Code Manual definition of code 77470 is special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation). We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the special treatment procedure. Our reviewer says that CPT code 77470 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to support billing 77470 on November 30, 2020, therefore this service cannot be considered for reimbursement. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the special treatment procedure have not been met. Therefore, we decided that the Plan does not have to pay for the special treatment procedure (77470) provided on November 30, 2020, through December 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on December 23, 2020.
You asked the Plan to waive the copayment for ambulance services. 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 a $300 copayment for ambulance services. You have been asked to pay a $300 copayment for ambulance services. Ambulance services fall 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 ambulance services provided on December 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia provided on November 23, 2020.
You asked the Plan to pay for anesthesia for percutaneous image guided procedures on the spine and spinal
cord; therapeutic (01936). You say that the enrollee benefited from the sedation due to the invasiveness of the
procedure and the sensitive surrounding anatomy. The Plan denied your request. The Plan says the medical
record does not establish the need for this sedation.
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 pay for anesthesia for percutaneous image guided
procedures on the spine and spinal cord; therapeutic (01936). Our reviewer says that the anesthesia was not
medically necessary. Our physician reviewer found the enrollee underwent epidural injections. The provided
medical records do not indicate the presence of any unique circumstances that support the need for monitored
anesthesia care. The elements of the coverage determination are not satisfied. The requested service cannot be
recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of anesthesia for percutaneous image guided procedures on the spine and spinal
cord; therapeutic (01936) have not been met. Therefore, we decided that the Plan does not have to pay for
anesthesia provided on November 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection (64483, 64484).
You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not medically necessary.
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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that you have chronic low back and hip pain. You have had two epidural steroid injections. The first injection provided significant relief but the second injection provided only short-lived relief. The failure of the second injection to provide sustained significant relief does not meet criteria for repeating the injection. Therefore, the request is considered not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection (64483, 64484).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L1833, L2397) provided to the enrollee on August 21, 2020.
You asked the Plan to pay for the services. You say that the prescription, proof of delivery, and clinical records were provided. The Plan denied your request. The Plan says the documentation submitted did not sufficiently show the enrollee's medical condition to support medical necessity.
The Plan must follow Medicare rules. Medicare rules say that a knee orthosis is covered if there is recent injury or knee instability shown on exam. 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records show that the enrollee has had chronic low back pain for four years. There is a diagnosis of osteoarthritis. Criteria for the brace is not met, as there is no instability or fracture present. The brace is not needed. We looked at this physician's review, the file, and Medicare rules. Apart from the lack of medical necessity, there is not enough evidence in the case file of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for orthoses (L1833, L2397) provided to the enrollee on August 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent transportation provided to the enrollee on February 5, 2021.

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says there was no authorization.

Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the enrollee was being transferred from acute care to a rehabilitation facility. The enrollee was in no distress and was transported on a stretcher. The transporting crew indicated the transfer was non-emergent. The record does not indicate why other forms of transportation were contraindicated. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent transportation provided to the enrollee on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for chiropractic services provided from October 12, 2020, to December 23, 2020.
You asked the Plan to waive the copayments for chiropractic services. You say that you 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 $20 copayment for chiropractic services. You received chiropractic services from October 12, 2020, to December 23, 2020, for a total of 17 visits. Therefore, you are responsible to pay the total amount of $320, which is less than the total copayment amount. You have been asked to pay the total copayment amount of $320 for chiropractic services. Chiropractic services fall within the chiropractic 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 copayments for chiropractic services provided from October 12, 2020, to December 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the defibrillator removal and replacement provided on August 21, 2020.
You asked the Plan to waive the coinsurance for the defibrillator removal and replacement. You say that you don't have another insurance company to pay for this charge. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of the cost for each outpatient hospital and ambulatory surgery visit. You have been asked to pay $5,048.13, which is 20% of the allowed amount for the defibrillator removal and replacement. The allowed amount is $25,240.67 (20% x $25,240.67 = $5,048.13). The defibrillator removal and replacement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 defibrillator removal and replacement provided on August 21, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental health services provided by a participating provider on December 3, 2020, to December 17, 2020.
You asked the Plan to waive the copayment for outpatient mental health services. You say that your card says that there is a $35 copayment for specialist services. The Plan denied your request. The Plan says the correct copayment has been 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 $40 copayment for outpatient mental health care/in-network/individual therapy. You have been asked to pay a $40 copayment for each outpatient mental health services. The total amount you are being asked to pay is $80 ($40 x 2 sessions = $80). Outpatient mental health services fall within the outpatient mental health care/in-network/individual therapy 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 outpatient mental health services provided by a participating provider on December 3, 2020, to December 17, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the core build up (D2950 x3), the pontic - porcelain fused to high noble metal (D6240 x3), and retainer crown - porcelain fused to high noble metal (D6750 x3) received October 5, 2020.
You asked the Plan to pay for the dental services. You say that the requested services are covered, and the Plan should pay its share. The Plan denied your request. The Plan says that porcelain crowns are not covered for molars, and charges for onlays or crowns installed at multiple abutments are excluded from coverage.
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 50% coinsurance for fixed prosthodontic services (crowns and pontics), and major restorative services (core buildup). We looked at your contract with the Plan and the file. The Plan states that porcelain crowns are not covered for molars, however this exclusion is applicable to the optional dental HMO plan, and you are noted to have the dental PPO plan. In addition, the Plan states "charges for onlays or crowns installed as multiple abutments" are excluded from coverage, however there is no explicitly stated rule in the EOC that states a bridge for three teeth would be noncovered. We find that this description of this exclusion could not be reasonably interpreted as limiting coverage of the bridge or the retainer crowns. The Plan contract states that fixed prosthodontic services, and major restorative services, when rendered by an in-network provider, require 50% coinsurance. You received the requested services from a contract plan provider, and you were not informed by this provider that the services would be non-covered. There is no clear exclusion in the EOC for these services. Based on this information, we find that there was no reasonable expectation that these services would be denied based on the information available to you in the Plan contract. Therefore, we decided that the Plan must pay their share of the cost for the core build up (D2950 x3), the pontic - porcelain fused to high noble metal (D6240 x3), and retainer crown - porcelain fused to high noble metal (D6750 x3) received October 5, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out of network (OON) provider on December 20, 2019.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out of network (OON) provider on December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 the services provided by an out-of-network provider on November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0482) provided on September 2, 2020.
You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0482) provided on September 2, 2020.