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

We decided that the Plan does not have to waive the copayment for the comprehensive eye exam (92004) fluorescein angiography (92235) fundus photography (92250) provided June 10, 2020.
You asked the Plan to waive the copayment for the vision services. You say that you do not feel that you owe an additional $25.You are being balance billed due to the provider being out of network. The Plan denied your request. The Plan says the claim was processed, and the correct copayment was applied per the Evidence of Coverage.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $60 copayment for all other eye exams to diagnose and treat diseases of the eye provided by an out of network provider. You have been asked to pay $60 copayment for the vision services. The vision services fall within the Vision 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 comprehensive eye exam (92004) fluorescein angiography (92235) fundus photography (92250) provided June 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance services provided on April 23, 2020.
You asked the Plan to waive the copay for the services provided. You say that the cost should be waived due to being Covid related. The Plan denied your request. The Plan says the copay 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copay for Medicare-covered ambulance transport. The enrollee has been asked to pay a $225 copay for Medicare-covered ambulance transport. The services fall within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the ambulance services provided on April 23, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management provided on July 3, 2020.
You asked the Plan to pay for the hospital discharge day management. 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 hospital discharge day management provided on July 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services (HCPCS S9502) provided to
the enrollee from December 3, 2018, to December 12, 2018.
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 this is an invalid procedure code for this service.
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 HCPCS code S9502 is "Home infusion therapy, antibiotic,
antiviral, or antifungal therapy; once every 8 hours, administrative services, professional pharmacy services,
care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per
diem."
We find that HCPCS code S9502 is not supported in the medical record. Specifically, this code has a status
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for
Medicare purposes. 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 home infusion therapy services
(HCPCS S9502) provided to the enrollee from December 3, 2018, to December 12, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the 8-inch wheels for the walker provided September 23, 2020.
You asked the Plan to pay for the 8-inch wheels. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is a deluxe/upgraded item and not eligible for payment. Therefore, we decided that the Plan does not have to pay for the 8-inch wheels for the walker provided September 23, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a low dose CT scan for lung cancer screening for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is not medically necessary. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found the enrollee's age is 67 with a smoking history of more than 40 pack-years. The interval since smoking cessation is three years. The enrollee meets the recommendations and criteria for this screening. 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 scan have been met. Therefore, we decided that the Plan has to pre-approve a low dose CT scan for lung cancer screening for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetes testing services (A4253, A4259) provided April 24, 2020, to July 23, 2020.
You asked the Plan to pay for the diabetes testing services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says criteria has not been met.
The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary. Therefore, we decided that the Plan does not have to pay for the diabetes testing services (A4253, A4259) provided April 24, 2020, to July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth consultation provided by an out-of-network provider on August 8, 2020.
You asked the Plan to pay for the telehealth consultation. You say that your office provides telehealth services for the nursing home the enrollee resides in. You say that the enrollee has authorization to be in the nursing home. The Plan denied your request. The Plan says this provider is not a network provider 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 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 telehealth consultation provided by an out-of-network provider on August 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and two resin-based composites provided on July 31, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation and resin-based composites. You say that you were not advised that you would be charged for these services. The Plan denied your request. The Plan says problem focused limited oral evaluation is not a covered service. The Plan also says that you were charged correctly for the resin-based composites at a 50% coinsurance.
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 problem focused limited oral evaluation is not among those covered under this benefit. The contract also clearly states that you must pay a 50% coinsurance for restorations received in-network. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation and two resin-based composites provided on July 31, 2019.
Your complaint about being upset with the Plan 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided August 6, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the lumbar-sacral orthosis was
medically necessary. The Plan denied your request. The Plan says there is no evidence the prescribing
physician ever saw the member.
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is covered when the Medicare
criteria cited in the Rules section are met.
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 lumbar-sacral orthosis (L0650). Our
reviewer says that the requested item was not medically necessary and reasonable. Our physician reviewer
found an appropriate history and a physical examination of the back would reasonably be required to
adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met.
The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the
covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible
physical examination of the back.
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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided
that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided August 6, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to provide reimbursement for the outpatient hospital services provided by the Clinic facility.

You asked the Plan to provide reimbursement for the outpatient hospital services. You say that you went to the emergency room but were told later by the provider that they would not bill for emergency care during the daytime. However, you feel that you went to an emergency clinic and should not be charged more than $90 for this. The Plan denied your request. The Plan says that the correct cost sharing was applied at 45% for non-emergency out of network care.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan forwarded this case to Maximus due to missing the time frame to render a decision. Based on review of the available information, there is a dispute between the services rendered and what was billed by the provider. You state that this was an emergency room visit so the $90 copayment should apply, although the services were billed as standard outpatient clinic visits. The Plan indicated that records were requested from the provider, but there are no requests documented in the file. We are therefore unable to verify whether this was an emergency room visit. However, the diagnoses associated with these visits are noted to be low potassium and fever, both of which could constitute a medical emergency as you report your temperature was 103 degrees. We do not find that the evidence is sufficient to support the Plan's decision to apply the out of network cost sharing to these services. We find that a $90 copayment would be applicable to each visit, but the remainder must be reimbursed by the Plan. Therefore, we decided that the Plan has to provide reimbursement for the outpatient hospital services provided by the Clinic facility.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve implantation of CardioMEMS device (33289).
You asked the Plan to pre-approve implantation of CardioMEMS device. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the clinical value and effectiveness has not been established in the setting of congestive heart failure.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 implantation of CardioMEMS device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the CardioMEMS device is being prescribed for an enrollee who has an approved indication for the device. Literature is available that supports its efficacy in this population. Therefore, the requested service satisfies the elements of the controlling rule and coverage is recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of implantation of CardioMEMS device have been met. Therefore, we decided that the Plan has to pre-approve implantation of CardioMEMS device (33289).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the conversion of external biliary drainage catheter to internal-external biliary drainage catheter services coded 47535 and the moderate sedation services coded 99153 and 99152 provided on October 3, 2020.
You asked the Plan to pay for the conversion of external biliary drainage catheter to internal-external biliary drainage catheter services and the moderate sedation 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 payable.
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 codes 47535, 99153, and 99152 are not supported in the medical record. Specifically, these services were billed with place of service 22 (outpatient. The documentation supports that the enrollee was inpatient for this date of service. Based on this information, we decided that Medicare rules for coverage of the conversion of external biliary drainage catheter to internal-external biliary drainage catheter services and the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the conversion of external biliary drainage catheter to internal-external biliary drainage catheter services coded 47535 and the moderate sedation services coded 99153 and 99152 provided on October 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile x-ray services.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.

The Plan must follow Medicare rules. The rules say that the SNF must submit ALL Medicare claims for ALL the services that its residents receive under Part A.

We looked at the file and Medicare rules. The file shows that the x-ray services were rendered while in a SNF. Payment is included in the SNF consolidated billing. 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 pay for the mobile x-ray services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical assistant services provided during a total hip replacement by a Certified Surgical Assistant (CSA).

You asked the Plan to pay for the surgical assistant services. You say that these services were medically necessary and should be reimbursed. The Plan denied your request. The Plan says these services are not separately payable when rendered by a CSA.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the surgical assistant services provided during a total hip replacement by a Certified Surgical Assistant (CSA).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray.

You asked the Plan to pay for the chest x-ray. You say that the enrollee's hospice care was revoked, when the enrollee was admitted as an inpatient. 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from October 5, 2020, to
October 14, 2020, by an OON provider.
You asked the Plan to pay for psychotherapy services. You say that you would like this claim reprocessed and
paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that
there are in-network providers available 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 had network providers
available who could have provided 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 psychotherapy services provided from October 5,
2020, to October 14, 2020, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided on September 30, 2020.
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that you were unable to run during the stress test, so the doctor recommended the perfusion imaging. You say that you were unaware it would cost $250, and you cannot afford it. 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 $250 per day for Medicare-covered diagnostic radiology services. You have been asked to pay a $250 copayment for the myocardial perfusion imaging. The myocardial perfusion imaging 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 myocardial perfusion imaging provided on September 30, 2020.