Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye surgery you had at an outpatient hospital facility.

You asked the Plan to waive the copayment for the eye surgery. You say that you do not think you should have to pay anything for this service because it was your understanding that this service would be paid in full under your VA benefits. The Plan denied your request. The Plan says you were charged this copayment 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 a $450 copayment for surgery at an outpatient hospital.

You have been asked to pay a $450 copayment for the eye surgery. the eye surgery falls within the surgery at an outpatient hospital 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 eye surgery you had at an outpatient hospital facility.

Your statement regarding payment of this claim under your VA benefits is not a valid appeal for medical coverage through Maximus. This part of your complaint is a grievance that must be answered by your VA administrator. Medicare does not permit us to make a decision about these types of issues.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the podiatry visit provided on December 7, 2020.

You asked the Plan to reduce the copayment for the podiatry visit. You say that you paid a $25 copayment at the time of the visit and that was the amount you expected to pay based on your plan material and membership card. The Plan denied your request. The Plan says you have been asked to pay 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 $50 copayment for each Medicare-covered visit for podiatry services. 

You have been asked to pay a $50 copayment for the podiatry visit. The podiatry visit falls within the "Podiatry 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 reduce the copayment for the podiatry visit provided on December 7, 2020.

Your complaint about misleading information is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a sleep study provided by a participating provider on August 24, 2020, to September 30, 2020.

You asked the Plan to waive the copayment for a sleep study. You say that you should have a $0 copayment for this. 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 $95 copayment for outpatient diagnostic tests/diagnostic tests. 

You have been asked to pay a $95 copayment for each sleep study. The total amount you are being asked to pay is $190 ($95 x 2 sleep studies = $190). A sleep study falls within the outpatient diagnostic tests/diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a sleep study provided by a participating provider on August 24, 2020, to September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364), preventive procedure (D1999), and problem focused limited oral evaluation (D0140).

You asked the Plan to pay for the cone beam CT capture and interpretation, preventive procedure, and problem focused limited oral evaluation. You say that you believe these services should be covered. The Plan denied your request. The Plan says the cone beam CT capture and interpretation and preventive procedure are not covered benefits under your dental plan. The Plan also says that the problem focused limited oral evaluation exceeds the frequency limitation in your benefit plan.

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, cone beam CT capture and interpretation (D0364) and unspecified preventive procedure (D1999) are not among those covered under this benefit. The contract also clearly states that problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) and your problem focused limited oral evaluation (D0140) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364), preventive procedure (D1999), and problem focused limited oral evaluation (D0140).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on September 15, 2019.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was
submitted after the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.

The record shows that a claim for the services was not filed until September 23, 2020. This means that more
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that
the Plan does not have to pay for the services provided on September 15, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services you.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not Medicare eligible.

The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.

We looked at the file and Medicare rules. The provider in question is a marriage family therapist. This type of provider is not eligible to enroll in the Medicare program. Payment cannot be made to a provider who is not enrolled in the Medicare program. 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 the therapy services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing.

You asked the Plan to pay for the testing. You say that payment should be made. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that refer to the MolDX website for covered and excluded tests' specific coding and billing information.

We looked at the file and Medicare rules. Per the MolDX website, the requested Cxbladder testing has not been approved for coverage. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MRI spinal canal and contents, lumbar; without contrast material (CPT code 72148), for the enrollee.

You asked the Plan to pre-approve the MRI. You say that the scan is necessary. The Plan denied your request. The Plan says the scan is not necessary.

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 physician reviewer found the enrollee reports radiation to the left leg and foot but no saddle anesthesia, night pain, or incontinence. No direct physical examination of her back or lower extremities to evaluate sensory or strength was documented. MRI lumbar spine was requested. No report on prior and recent efforts with physical therapy or other conservative treatments were documented. In order to justify MRI, full exhaustion of conservative care and objective signs (besides positive straight leg test only) showing radiculopathy or other red flag diagnosis must be evidenced in the records which is not the case here. Therefore, this request for MRI will be considered not medically necessary based on the provided documentation.

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 Plan does not have to pre-approve the MRI spinal canal and contents, lumbar; without contrast material (CPT code 72148), for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on June 19, 2020.

You asked the Plan to pay for the infectious agent detection by nucleic acid. You say that you believe this service should be covered. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on June 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic device.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The services are considered experimental/investigational in nature and not medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing.

You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because Guardant360 testing is a Medicare covered benefit. The Plan denied your request. The Plan says the Guardant360 panel must be billed with procedure code 81479.

The Plan must follow Medicare rules. Medicare rules say that one unit of CPT code 81479 is used to report Guardant360 testing.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Specifically, this service has not been reported correctly. One unit of CPT code 81479 is used to report this testing but this claim has been billed as a panel of codes. Therefore, we decided that the Plan does not have to pay for Guardant360 testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on August 12, 2020 and October 2, 2020.

You asked the Plan to waive the copayment for the laboratory services. You say that you shouldn't be required to pay an additional cost for services you didn't request. You say that the provider should be responsible for the copayments. The Plan denied your request. The Plan says the copayments 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 a $5 copayment for each lab visit for clinical and diagnostic lab services. 

You have been asked to pay a $5 copayment for each visit for laboratory services. The total amount you owe is $10 ($5/visit x 2 visits = $10). Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory services provided on August 12, 2020 and October 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ibrance.

You asked the Plan to pre-approve Ibrance. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 pre-approve Ibrance.

Benefits for Ibrance 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the infusion pump analysis and refill provided on October 7, 2020.

You asked the Plan to waive the copayment for the infusion pump analysis and refill. You say that this procedure has been done numerous times and has never had an extra copayment. You say that the claim should be covered. The Plan denied your request. The Plan says the copayment 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 a $200 copayment for each outpatient hospital and observation service. 

You have been asked to pay a $200 copayment for the infusion pump analysis and refill. The infusion pump analysis and refill fall 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 copayment for the infusion pump analysis and refill provided on October 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 15, 2019.

You asked the Plan to pay for the subsequent nursing facility care. You say that you did not receive proper notice of this enrollee's benefit determination which is why the claim was submitted untimely. You also say that the physician provided medically necessary services to the enrollee in good faith. The Plan denied your request. The Plan says the corrected claim was received past the allowed 12 month time frame.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the subsequent nursing facility care was not filed until October 12, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397).

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were medically necessary. The Plan denied your request. The Plan says there was no evidence of an established relationship between the prescribing physician and the enrollee.

The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the knee orthosis and suspension sleeve. Our reviewer says that the items provided were not medically necessary and reasonable. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 

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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the crown (D2740).

You asked the Plan to pay for the dental services. You say that you broke your tooth on a Friday and had to go to an Emergency Dental Clinic as a result. You also say that you did not have a choice as no other dentist were open. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says periapical x-ray is not listed as a covered service. The Plan says crown is not listed as a covered service either. The Plan also says that you did not contact them to verify your benefits prior to the date of 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the crown (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wig (A9282) provided September 17, 2020.

You asked the Plan to pay for a wig. You say that this request was medically necessary. The Plan denied your request. The Plan says this is not a covered service.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. 

In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig (A9282) provided September 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 19, 2020.

You asked the Plan to pay for the dental service. You say that your tooth had broken in half. You say that it was making you sick. You also say that the plan denied every time you go to the dentist. The Plan denied your request. The Plan says 1 limited oral evaluation per plan year. The Plan also says that the frequency limit has been exceeded.

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 and limited oral evaluation is a covered service, the frequency limit of 1 per plan year has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on July 21, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis panel testing (FoundationOne Heme test) provided on October 5, 2020.

You asked the Plan to pay for genetic testing. You say that this testing is a proven medically necessary covered benefit. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not covered.

The Plan must follow Medicare rules. Medicare rules say that genetic testing code will be automatically denied by Medicare as not medically necessary and is therefore not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis panel testing (FoundationOne Heme test) provided on October 5, 2020.