Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses delux frames (V2025) and progressive lens, per lens (V2781) provided on October 31, 2019 by an out-of-network vision provider.
You asked the Plan to pay for the eyeglasses. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says there is no out-of-network coverage for the services rendered.
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. We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Review of the file show that you received eyeglasses delux frames (V2025) and progressive lens, per lens (V2781) provided on October 31, 2019 by an out-of-network vision provider. Your EOC states, your vision benefit is through a supplemental network vision care provider. However, you did not use a network provider. Therefore, we decided that the Plan does not have to pay for eyeglasses delux frames (V2025) and progressive lens, per lens (V2781) provided on October 31, 2019 by an out-of-network vision provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that neither the referring provider nor the enrollee had any choice as to where the specimen was sent for testing. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on August 15, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on September 18, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says payment of this service is bundled into other 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. We find that CPT code 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ostomy supplies rendered to you on February 18, 2020.
You asked the Plan to waive the coinsurance for these services. You say that you did not receive a bill previously for these services. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for medical supplies.
Review of the file shows that you received ostomy supplies on February 18, 2020. You have been asked to pay a 20% coinsurance for these services, for a total of $30.28. These services fall within the medical 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 coinsurance for the ostomy supplies rendered to you on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neurophysiologic monitoring (G0453, 95938, 95861) provided on September 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for intraoperative neurophysiologic monitoring. You say that these services were provided at an in-network facility. The Plan denied your request. The Plan says these 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the intraoperative neurophysiologic monitoring (G0453, 95938, 95861) provided on September 17, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgical service provided on December 30, 2019.
You asked the Plan to waive the copayment for outpatient surgery. You say that this appointment took less than 10 minutes and should be considered an office visit. 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 $250 copayment for outpatient surgery at an outpatient hospital facility. You have been asked to pay $250 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 surgical service provided on December 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered to you on November 12, 2019.
You asked the Plan to waive the copayment for these services. You say that you disagree with the reimbursement. The Plan denied your request. The Plan says the claim was processed 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 35% coinsurance for out-of-network outpatient surgery.
Review of the file shows that you received outpatient surgical services on November 12, 2019 from an out-of-network provider. The Plan reimbursed the Medicare allowed amount for these services minus your coinsurance. You have been asked to pay a 35% coinsurance for these services. These services fall within the out-of-network outpatient surgery 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 outpatient surgical services rendered to you on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation (G0483) provided on November 19, 2019 and December 10, 2019.
You asked the Plan to pay for the electrical stimulation. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that these services are not a covered benefit under the enrollee's contractual policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the electrical stimulation (G0483) provided on November 19, 2019 and December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for dermatology services provided on January 22, 2020.
You asked the Plan to waive the copayment for dermatology services. You say that you were told there would be no copayment for this visit. 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 $35 copayment for in-network specialist office visit. You have been asked to pay $35 copayment for dermatology services. Dermatology services fall 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 copayment for dermatology services provided on January 22, 2020.
Your complaint regarding receiving inaccurate information about the cost-share for these services is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 64636 provided on November 18, 2019.
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 64636 is destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure). We find that CPT code 64636 is not supported in the medical record. Specifically, three units of this code were billed. The documentation submitted did not support the units billed. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded 64636 provided on November 18, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a duplex scan provided on July 18, 2018.
You asked the Plan to waive the coinsurance for duplex scan. You say that you feel it is unacceptable to be billed this amount after a year and a half. 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 duplex scan. The allowed amount of the claim is $1,019.72, resulting in a coinsurance obligation of $203.94. You have been asked to pay 20% coinsurance for duplex scan. Duplex scan 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 coinsurance for a duplex scan provided on July 18, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on November 21, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the plan did not authorize any services for a non-participating provider.
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 rendering provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for office visit services provided to the enrollee on November 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunoassay (83516) provided on September 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an OON immunoassay. You say that this should be covered. The Plan denied your request. The Plan says this was 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the immunoassay (83516) provided on September 10, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse the sales tax of the electric lift chair purchased on May 17, 2019.
You asked the Plan to reimburse you for the seat lift mechanism and sales tax. You say that the seat lift chair is medically necessary for the enrollee. The Plan denied your request. The Plan says they will reimburse you the Medicare fee schedule rate minus your cost-sharing and sales tax.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. We looked at the file and Medicare rules. On March 12, 2020 the Plan reimbursed you for the seat lift mechanism minus your cost share and sales tax. Medicare does not separately pay sales tax. Therefore, we decided that the Plan does not have to reimburse you the sales tax of the electric lift chair purchased on May 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the endovenous ablation therapy services provided on January 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the endovenous ablation therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the endovenous ablation therapy services provided on January 2, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from October 15, 2019 to October 21, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you want to know who you owe money to. 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 $370 copayment each day for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from October 15, 2019 to October 21, 2019. Therefore, you are responsible to pay a $370 copayment for days 1-5 (October 15, 2019 to October 19, 2019). $370 (copayment) x 5 (inpatient days) = $1,850. You have been asked to pay the total copayment amount of $1,850 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided from October 15, 2019 to October 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ultomiris for the enrollee.
You asked the Plan to pre-approve Ultomiris. You say that all other treatments have failed for the enrollee. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Ultomiris. Our reviewer says that Ultomiris is not medically reasonable and necessary for the enrollee in this case. Ultomiris is not currently FDA approved for the diagnosis of Myasthenia Gravis. The use of Ultomiris is not currently supported within the Compendia. The use of this drug is not indicated, supported or recommended in any of the compendia. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Ultomiris. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ultomiris have not been met. Therefore, we decided that the Plan does not have to pre-approve Ultomiris for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99309) provided on October 24, 2019.
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers available.
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 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 for the nursing facility care (99309) provided on October 24, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided to the enrollee on July 1, 2019.
You asked the Plan to pay for the paramedic intercept services. The Plan denied your request. The Plan says that these services are not covered.
The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the services are furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided to the enrollee on July 1, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on October 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says there is no network deficiency for the services, and alternate network providers were found.
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 physical therapy services provided on October 22, 2019 by an out of network (OON) provider.