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

We decided that the Plan does not have to pay for SNF care provided to the enrollee from July 15, 2019 through August 13, 2019.
You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from July 15, 2019 through August 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection of hyaluronan provided by the PA on October 2, 2019.
You asked the Plan to waive the coinsurance for injection. You say that you were never told in advance that you should expect to pay this amount, and you are on a fixed income and cannot afford this amount. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for injection. The allowed amount of the injection is $3,825, resulting in a coinsurance obligation of $765. You have been asked to pay 20% coinsurance for injection. Injection falls within the Medicare Part B Prescription Drugs 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 injection of hyaluronan provided by the PA on October 2, 2019.
Your complaint regarding not being told about the cost-share for this service is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the health plan for more information about your grievance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 70 additional acupuncture visits over 3 months.
You asked the Plan to pre-approve the additional visits. The Plan denied your request. The Plan says the visits are not necessary.
The rules say that acupuncture services are not covered by Medicare. However, the Plan offers an acupuncture benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers acupuncture only when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional visits. Our reviewer says that the requested 70 additional acupuncture visits over 3 months are not medically reasonable and necessary. Our physician reviewer found that there is insufficient documentation to show that the requested acupuncture visits, in excess of those covered by the plan, are medically necessary and reasonable. 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 70 additional acupuncture visits over 3 months.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided by on July 1, 2019.
You asked the Plan to waive the copayment for the ultrasound. You say that you receive this service yearly and have never had to pay a $100 copayment before. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls 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 ultrasound provided on July 1, 2019.
Our decision is only about the July 1, 2019 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on August 2, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation for the proof of delivery reflects a different date of service than the itemized billing/shipping invoice.
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 shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The different documents reflect a different date of service, so the billed service and proof of delivery cannot be verified. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on August 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on August 13, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
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 has network providers available who can provide 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 to the enrollee by an out-of-network provider on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit services provided on July 24, 2019.
You asked the Plan to waive the copayment for the office visit 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 office visit services on the date of service at issue in this appeal. The plan states the correct copayment has 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 $10 copayment for each covered visit or consultation in an outpatient location with your PCP or other primary care physician. We looked at the file, the Plan's contract and Medicare rules. The file shows you received office visit services on July 24, 2019. You have been asked to pay a $10 copayment for the office visit services. The office visit services fall within the Physicians/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 the office visit services provided on July 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.You asked the Plan to pre-approve Prolia. You say that not approving Proliaat this time will certainly increase the enrollee's risk for vertebral fractures.The Plan denied your request. The Plan says that they need more information explaining the patient's condition.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee in this case. Based on the enrollee's T-scores from 2016 and 2018, the enrollee is noted to have osteopenia, not osteoporosis. There is no evidence that the enrollee is using an aromatase inhibitor, is using long-term glucocorticoids, has bony tumors or has hypercalcemia related to malignancy. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for Prolia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulatory surgery center services provided on September 5, 2019 and September 19, 2019.
You asked the Plan to waive the copayment for ambulatory surgery center services. The Plan denied your request. The Plan says there is a $150 copayment for outpatient surgeries performed at an ambulatory surgical center.
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 $150 copayment for ambulatory surgical center. You have been asked to pay $150 copayment for each ambulatory surgery center service. The ambulatory surgery center services fall within the ambulatory surgical center 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 ambulatory surgery center services provided on September 5, 2019 and September 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided on August 19, 2019.You asked the Plan to pay fortest strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery 
Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the 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 shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided on August 19, 2019
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided from February 18, 2019, to May 28, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not eligible to bill Medicare.
The Plan must follow Medicare rules. Medicare rules say that the above providers are not eligible to enroll in the Medicare program. We looked at the file and Medicare rules. Provider is a profession counselor. Professional counselors are not eligible to enroll in the Medicare program. Payment cannot be made to providers who are 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 services provided from February 18, 2019, to May 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chemodenervation by the provider on July 8, 2019.
You asked the Plan to waive the copayment for chemodenervation. You say that the procedure did not work for you and 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 $275 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received chemodenervation on July 8, 2019. Chemodenervation is considered a surgical procedure. Therefore, you are responsible to pay the $275 copayment. You have been asked to pay a $275 copayment for chemodenervation. Chemodenervation falls within the outpatient surgery and other medical 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 chemodenervation provided by the provider on July 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided by HNC Medical Supplies from July 23, 2019 to October 11, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the 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 shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided by HNC Medical Supplies from July 23, 2019 to October 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids, accessories and fittingprovidedon August 13, 2019.You asked the Plan to reimburse you for the hearing aids, accessories and fitting. The Plan denied your request. The Plan says hearing aidmust be purchased through the provider to be covered. Hearing aid accessories and fittings are excluded from coverage.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered directly from the provider.We looked at the file and the Plan's rules. The requested provider in this case is not network hearing aid provider with the Plan. Hearing aid accessories and fittings are excluded from coverage. Therefore, we decided that the Plan does not have to reimburse you for hearing aids, accessories and fitting provided on August 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive drug testing and definitive drug testing panel provided on June 14, 2019.
You asked the Plan to pay for the presumptive and definitive testing panels. You say that the documentation is sufficient to support that this claim should be paid. The Plan denied your request. The Plan says the order form is dated after the date of service so this cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the treating provider. In this case, the case file does not contain any document that shows an order for lab testing nor any document with the results of the billed testing. The only document submitted from the provider is a form which establishes the provider's custom testing panel which is dated September 7, 2018. Without an order form or lab report, the services are not supported. Therefore, we decided that the Plan does not have to pay for the presumptive drug testing and definitive drug testing panel provided on June 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on April 15, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.Medicare rules say that plans can require enrolleesto 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 isnot a network provider with the Plan. The Plan has network providers available who can provide the services 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 these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided by an out-of-network provider on April 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on May 31, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on May 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for open treatment of a distal radial extra-articular fracture (25607) and neuroplasty (25607) provided on April 16, 2019.
You asked the Plan to pay for the open treatment of a distal radial extra-articular fracture and neuroplasty. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services are not supported in the medical record.
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 25607 is open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation. The CPT Code Manual definition of code 64718 is neuroplasty and/or transposition; ulnar nerve at elbow 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 open treatment of a distal radial extra-articular fracture and neuroplasty. Our reviewer says that CPT code 25607 is not supported. The record states that the patient had an intra-articular fracture. There is no evidence of treatment of an extra-articular fracture. Our reviewer found CPT code 64718 is not supported. There is no evidence that neuroplasty or transposition of the ulnar nerve was performed during this episode of care.
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 open treatment of a distal radial extra-articular fracture and neuroplasty have not been met. Therefore, we decided that the Plan does not have to pay for open treatment of a distal radial extra-articular fracture (25607) and neuroplasty (25607) provided on April 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on June 13, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided on June 13, 2019.