Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on January
13, 2020.
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that the Plan
should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not
indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be
verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for
the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthosis
(L1833) and suspension sleeve (L2397) have not been met. Therefore, we decided that the Plan does not have
to pay for the knee orthosis and suspension sleeve provided on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on January 16, 2020.
You asked the Plan to waive the copayment for the eye exam. You say that you've never had to pay before. You say that you shouldn't have to pay the copayment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each in-network, Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye. You have been asked to pay a $35 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show that a medical eye exam was performed. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the eye exam provided on January 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on February 18, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not be responsible for the copayment because you were taken to the wrong hospital. 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 $225 copayment for a Medicare-covered one-way trip. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services (PA)" 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 ambulance transport provided on February 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom-fabricated ankle-foot orthosis.
You asked the Plan to pre-approve the orthosis. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of a trial and failure of a pre-fabricated brace.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the orthosis. Our reviewer says that the requested orthosis is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documented ankle instability or deformity. A failure to respond to prefabricated ankle orthoses is not documented. As such, this request is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom-fabricated ankle-foot orthosis.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography provided on October 31, 2019.
You asked the Plan to pay for the echocardiography. You say that the enrollee was discharged from hospice on
October 9, 2019. 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 on October 9, 2019. 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
echocardiography provided on October 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the echocardiography provided on
December 3, 2019.
You asked the Plan to waive the coinsurance for the echocardiography. You say that you already paid a $395
copayment. You say that this should be part of the procedure. The Plan denied your request. The Plan says the
coinsurance 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 20%
coinsurance for each Medicare-covered radiological diagnostic service.
You have been asked to pay $116.53, which is 20% of the allowed amount for the echocardiography. The
allowed amount is $582.65 (20% x $582.65 = $116.53). The echocardiography 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 the echocardiography provided on December 3, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rezum therapy.
You asked the Plan to pre-approve Rezum therapy. You say that the requested Rezum therapy is medically necessary. The Plan denied your request. The Plan says the requested Rezum therapy is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Rezum therapy. Our reviewer says that the requested Rezum therapy is not medically necessary. Our physician reviewer found the requested Rezum therapy is not medically reasonable and necessary for the enrollee in this case. The Rezum System is indicated for men 50 years and older with a prostate volume between 30cm3 and 80cm3. The Rezum System is also indicated for treatment of prostate with hyperplasia of the central zone and/or a median lobe. The use of Rezum is contraindicated for patients with a urinary implant or who have a penile prosthesis. In this case, the prostate size (95cm3) is greater than the indicated volume(between 30cm3 and 80cm3). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rezum therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Rezum therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the records show the ability to walk a total 100 feet with someone standing next to the
enrollee.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR, outpatient
rehabilitation, LTC).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan has to pre-approve removal of lining of tendon covering of wrist services.
You asked the Plan to pre-approve removal of lining of tendon covering of wrist services. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested
services are not medically necessary.
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 removal of lining of tendon covering of
wrist services. Our reviewer says that the requested items/services are considered medically reasonable and
necessary in this case. Our physician reviewer found the enrollee presents with persistent left wrist pain with
lifting and gripping activities, especially repetitive activities involving the thumb. Clinical exam findings have
been consistent with deQuervain's tenosynovitis. The enrollee underwent one cortisone injection with
temporary benefit for one week. The enrollee has failed to improve despite conservative treatment, including
activity modification, medications, nighttime bracing, and occupational therapy. Under consideration is a
request for left first dorsal compartment release (CPT code 25118). Current evidence based medical literature
supports surgical intervention for recalcitrant deQuervain's tenosynovitis. This enrollee failed to achieve
sustained improvement with a cortisone injection and does not want another injection. She has otherwise failed
long-term reasonable and/or comprehensive treatment. Therefore, she has a diagnosis, condition and symptoms
that meet Medicare criteria for deQuervain's release. The requested surgical intervention would be considered
the standard of care and medically reasonable and necessary for treatment of the enrollee's medical condition at
this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of removal of lining of tendon covering of wrist services have been met.
Therefore, we decided that the Plan has to pre-approve removal of lining of tendon covering of wrist services.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on February 12, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 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 medical services provided by an out-of-network provider on February 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 6, 2020.
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 procedure codes 80307 and G0480 are not supported.
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 80307 is presumptive drug testing, any number of
classes. The definition of code G0480 is definitive drug testing, 1-7 classes.
We find that CPT codes 80307 and G0480 are not supported in the medical record. Specifically, the submitted
lab results do not indicate the method of test utilized for presumptive drug testing to support code 80307 or for
the definitive testing to support code G0480. 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
drug testing rendered on January 6, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an MRI scan of the shoulder.
You asked the Plan to pre-approve an MRI scan. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says that the requested MRI is not medically necessary.
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. Review of the file shows that the plan states that you have a 2-3 week history of
left shoulder pain. The documentation also states that you had a physical exam which confirmed decreased
range of motion. While the plan denied the requested MRI due to not meeting medical necessity, no medical
records were provided to Maximus with the case file. Maximus requested medical records from the plan with
no response. The plan did not provide any medical records to support their denial. Therefore, we decided that
the Plan has to pre-approve an MRI scan of the shoulder.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits and does not have to
waive the coinsurance for a Medicare Part B drug provided from December 10, 2019 to December 31, 2019.
You asked the Plan to waive the copayments for specialist visits and to waive the coinsurance for a Medicare
Part B drug. You say that you met the MOOP amount and should not be responsible for 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 the
MOOP amount for 2019 is $5,500. Your contract with the Plan also clearly says that you must pay a $45
copayment per specialist visit.
You received specialist visits and a Medicare Part B drug from December 10, 2019 to December 31, 2019. The
record shows that due to the reprocessing of claims you had only paid $5,019.52 toward the $5,500 MOOP
amount. Therefore, you are responsible to pay a $40 copayment per each specialist visit. The total amount you
owe for specialist visits is $80. You are also responsible to pay your share of the cost -sharing charges for the
Medicare Part B drug. Therefore, you are responsible to pay $440.48, which is less than the 20% coinsurance
amount. The total amount you owe is: $520.48.
You have been asked to pay the total amount of $520.48 for specialist visits and a Medicare Part B drug.
Specialist visits fall within the physician/practitioner services, including doctor's office visits benefit category.
A Medicare Part B drug falls within the Medicare Part B drug 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 specialist visits and does not have to waive the coinsurance for a Medicare Part B
drug provided from December 10, 2019 to December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning (99497) provided on September 27,
2019.
You asked the Plan to pay for advance care planning. You say that this should be paid. The Plan denied your
request. The Plan says this code is not supported.
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 99497 is advance care planning including the explanation
and discussion of advance directives such as standard forms (with completion of such forms, when performed),
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient,
family member(s), and/or surrogate.
We find that CPT code 99497 is not supported in the medical record. Specifically, the medical records do not
document that face-to-face advanced care planning took place. Based on this information, we decided that
Medicare rules for coverage of advance care planning have not been met. Therefore, we decided that the Plan
does not have to pay for advance care planning (99497) provided on September 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CTA provided on November 2, 2019.
You asked the Plan to waive the copayment for the CTA. You say that you weren't informed there would be a
copayment for a CT scan. You say that you cannot afford the high copayment. The Plan denied your request.
The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225
copayment for each in-network, Medicare covered advanced imaging service (not including x-rays). Your
contract with the Plan clearly says that if advanced imaging services are received as part of an emergency
department evaluation then you will only pay the advanced imaging copayment, not the emergency room
copayment.
You have been asked to pay a $225 copayment for the CTA. The CTA 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 CTA provided on November 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for routine hearing services provided on
January 23, 2020.
You asked the Plan to waive the copayment for routine hearing services. You say that the services should be
covered without a copayment. The Plan denied your request. The Plan says the claims were processed correctly
and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $15 copayment for routine hearing services.
The enrollee has been asked to pay a $15 copayment for routine hearing services. Routine hearing services falls
within the routine hearing 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
copayment for routine hearing services provided on January 23, 2020.