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

We decided that the Plan does not have to pay for the ambulance services provided on September 14, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 14, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ultrasound and the specialist office visit provided on September 24, 2020 and October 8, 2020.
You asked the Plan to waive the copayments for the ultrasound and the specialist office visit. You say that the ultrasound should be waived because it was done during an office visit. You say you already paid for the office visit on October 8, 2020. 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 $100 copayment per day for Medicare-covered diagnostic radiology services and a $25 copayment for each covered visit or consultation in an outpatient location with a specialist. You have been asked to pay a $100 copayment for the ultrasound and a $25 copayment for the specialist office visit. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 the ultrasound and the specialist office visit provided on September 24, 2020 and October 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 14, 2020.
You asked the Plan to pay for the testing services. You say that the testing was conducted to ensure proper
usage of medication adherence, and to determine a need to alter the treatment plan. The Plan denied your
request. The Plan says without medical records that show why the testing is needed, coverage is denied.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
The file shows that definitive urine drug testing of 8-14 drug classes was provided. We looked at the file, and
Medicare rules. In this case, there is insufficient information to show the testing was ordered based on the
enrollee's history, clinical assessment, suspicious behaviors, or other clinician documented change in affect or
behavioral pattern. Based on this information, we decided that Medicare rules for coverage have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing services provided on October 14,
2020.
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 requested orthoses were medically necessary for the enrollee. The Plan denied your request. The Plan says there is no evidence the enrollee saw the provider.

The Plan follows Medicare rules. Medicare rules say that for the requested knee orthosis, knee instability must be documented by examination of the beneficiary and objective description of joint laxity.

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 requested items were not medically reasonable and necessary. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic treatment provided from October 7, 2020, through October 13, 2020.
You asked the Plan to pay for the chiropractic treatment. The Plan denied your request. The Plan says the services were received from a non-plan provider without prior authorization from the Plan.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for chiropractic treatment provided from October 7, 2020, through October 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cystourethoscopy provided on October
21, 2020.
You asked the Plan to waive the copayment for outpatient surgery. You say that you cannot pay this amount
every time you have this procedure. The Plan denied your request. The Plan says the copayment amount you
are being charged is correct.
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 $295
copayment for outpatient surgery at an outpatient hospital facility.
You have been asked to pay $295 copayment for outpatient surgery. Outpatient surgery 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 copayment for a cystourethoscopy
provided on October 21, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health aide services (S9122) provided on July 6, 2020, through July 30, 2020.
You asked the Plan to pay for the home health aide services. You say that you would like reconsideration based on the records submited. The Plan denied your request. The Plan says the record does not include documentation of a note and amount of time spent rendering the services.
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 S9122 is Home health aide or certified nurse assistant, providing care in the home; per hour. 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 home health aide services. Our reviewer says that CPT code S9122 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to verify that Home health aide or certified nurse assistant, providing care in the home; per hour were provided July 6, 2020 through July 30, 2020, therefore these services cannot be verified. 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 home health aide services have not been met. Therefore, we decided that the Plan does not have to pay for home health aide services (S9122) provided on July 6, 2020, through July 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the HHA or certified nurse assistant.

You asked the Plan to pay for the HHA or certified nurse assistant. The Plan denied your request. The Plan
says the home health aide services were rendered by a provider who is not under contract with the Health Plan,
and is not certified for Medicare.

The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items
or services, a provider or supplier must be enrolled in the Medicare program.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the HHA or certified nurse assistant have not been met. This provider is not part of the Medicare
program and is not payable. Therefore, we decided that the Plan does not have to pay for the HHA or certified
nurse assistant.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth distant site service (G2025) provided on May 28, 2020.
You asked the Plan to pay for the telehealth distant site service. You say that you would like reconsideration because guidelines have been updated indicating that services now only require G2025 to be reported. The Plan denied your request. The Plan says G2025 must be billed with additional codes and modifier 95.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. For telehealth distant site services furnished between January 27, 2020, and June 30, 2020 that are also FQHC qualifying visits, you must report 3 HCPCS/CPT codes We find that CPT code G2025 is not supported in the record. Specifically, these services were not billed with the required additional CPT codes or the appropriate modifier. Based on this information, we decided that Medicare rules for coverage of the telehealth distant site service have not been met. Therefore, we decided that the Plan does not have to pay for telehealth distant site service (G2025) provided on May 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from August 25, 2020, to September 11, 2020.
You asked the Plan to waive the copayment for SNF care. You say that you will not pay this bill and want these services to be covered by the Plan. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 per day for days 1 to 20 of a benefit period, a $140 copayment per day for days 21 to 44 of a benefit period, and a $0 copayment per day for days 45 to 100 of a benefit period for Skilled Nursing Facility (SNF) care. This SNF stay lasted 17 days, resulting in a total copayment amount of $340. You have been asked to pay a $20 copayment per day for days 1 to 20 of a benefit period, a $140 copayment per day for days 21 to 44 of a benefit period, and a $0 copayment per day for days 45 to 100 of a benefit period for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) care 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 SNF care provided from August 25, 2020, to September 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on August 21, 2020.
You asked the Plan to waive the copayment for non-emergent ambulance services. You say that this is way too high of a copayment. You say that you cannot walk, and you have no transportation to get to rehab. 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 $90 copayment for ambulance services. You have been asked to pay a $90 copayment for non-emergent ambulance services. Since non-emergent ambulance services were provided, the correct copayment has been applied. Non-emergent 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 an ambulance trip provided by a participating provider on August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an office visit provided on October 6,
2020.
You asked the Plan to waive the coinsurance for an office visit. You say that you disagree with the out-ofnetwork
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 50%
coinsurance for out-of-network physician/practitioner services, including doctor's office visits.
You received an office visit from an out-of-network provider on October 6, 2020. Therefore, you are
responsible to pay your share of the out-of-network charges. The total allowed amount is $44.27 and 50% of
that is $22.13.
You have been asked to pay the total coinsurance amount of $22.13 for an office visit. An office visit falls
within the physician/practitioner services, including doctor's office visits 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 an office visit provided on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99212) provided on June 24, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you feel the copayment should be waived because you saw a nurse practitioner. The Plan denied your request. The Plan says the copayment was 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 $15 copayment for a specialist visit. You have been asked to pay a $15 copayment for an office visit. The service at issue falls within the physician/practitioner 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 an office visit (99212) provided on June 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 31, 2020.
You asked the Plan to pay for the ambulance services. You say that your mother was treated in place by the
medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on August 31, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on August 31, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan for the enrollee.
You asked the Plan to pre-approve a PET scan. You say that this imaging is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen stating Maximus did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for am amyloid PET scan. The Maximus Physician Reviewer determined that the requested imagine may be beneficial. The Plan requested a reopen stating the Medicare coverage criteria for a PET scan in this setting are not met. The medical records show the enrollee is an 81-year-old man with a 5-year history of memory decline. A brain PET performed in September 2018 favored a temporal variant of frontotemporal dementia. Alzheimer's dementia was felt to be less likely. Our Medical Director has concluded the Plan is correct in this case. Medicare criteria for a beta amyloid PET scan states that one PET scan will be covered in the setting of dementia or neurodegenerative disease, with evidence development (CED), under 1862(a)(1)(E) of the Act, in clinical studies that meet certain criteria. The coverage criteria were not met in this case, as the enrollee previously had one PET CT scan. Furthermore, the documentation does not support that the enrollee was enrolled in a clinical study. 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown, core buildup, including any pins when required, full mouth debridement, maxillary partial denture, and adjunctive procedure provided by an OON provider.

You asked the Plan to pay for the crown, core buildup, full mouth debridement, maxillary partial denture, and adjunctive procedure. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services were performed by a provider who is not in the Plan's network and is outside of the country.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the crown, core buildup, including any pins when required, full mouth debridement, maxillary partial denture, and adjunctive procedure provided by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided by an OON provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that the doctor is not aware when authorization is obtained because these services are provided in an inpatient facility. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that prior authorization was not obtained by the provider or facility.

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 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 subsequent nursing facility care provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit with a specialist (99214) and the Computed Tomography (CT) scan of the chest (71250) provided on October 12, 2020.
You asked the Plan to waive the copayment for the CT scan and office visit. You say that you did not realize the copayment waiver for the office visits had ended and you did not know that the diagnostic imaging service would be so expensive. The Plan denied your request. The Plan says the copayments for these services were 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 $30 copayment for an office visit with a specialist and a $145 copayment for outpatient diagnostic radiological services. You have been asked to pay a $30 copayment for an office visit with a specialist and a $145 copayment for a CT scan, which falls within the outpatient diagnostic radiological 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 office visit with a specialist (99214) and the Computed Tomography (CT) scan of the chest (71250) provided on October 12, 2020.