Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit services provided to the enrollee from April 4, 2019.
You asked the Plan to pay for the home visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for the home visit have not been met. Specifically, this code may only be billed wen services are provided in the enrollee's private residence (place of service 12). To bill this code, the physician must be physically present in the beneficiary's home. The provided records do not support that a
physician or non-physician practitioner (PA or NP) were physically present.. Therefore, we decided that the Plan does not have to pay for the home visit services provided to the enrollee from April 4, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the supply allowance for therapeutic continuous glucose monitor (CGM) provided on October 15, 2020.
You asked the Plan to pay for the supply allowance. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the items rendered are not payable.
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 has denied this claim due to missing/incomplete/invalid procedure code(s) and that the claim/service lacks information or has submission/billing errors. The errors that the Plan says that the claim have are not identified in the documentation provided to Maximus. Medical records, physician order, and a proof of delivery were supplied by the provider in the documentation. The Plan's denial is not substantiated. Therefore, we decided that the Plan has to pay for the supply allowance for therapeutic continuous glucose monitor (CGM) provided on October 15, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the foot orthotics (L3001, L3040, L3060) provided on September 5, 2020.
You asked the Plan to issue reimbursement. You say that foot orthotics are medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of these items.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to issue reimbursement for the foot orthotics (L3001, L3040, L3060) provided on September 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you are capable of preforming everyday tasks on your own, but you are still needing assistance due to limited range of motion. The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about your condition; you do not meet the requirements.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for delirium and gastrointestinal bleeding. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Computed tomography (CT) head or brain (70450) provided January 8, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that this copay is kind of high and you were not expecting it to be $270. You feel that it should be $75. You have other tests coming up too that you have to pay for as well. Your income decreased and $270 is too much to pay for a CT scan. 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 $270 copay for advanced imaging services. You have been asked to pay $270 copay for the CT scan. The CT 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 copayment for Computed tomography (CT) head or brain (70450) provided January 8, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a participating provider on December 8, 2020.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that this was a screening and not a biopsy. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery/in-network. You have been asked to pay a $250 copayment for a diagnostic colonoscopy. The colonoscopy that was provided was diagnostic in nature; therefore, the correct copayment has been applied. A diagnostic colonoscopy falls within the outpatient surgery/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a participating provider on December 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the bicycle (99199), delivery and set up (A9901), and the sales tax (S9999) provided on December 19, 2019.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy or by Medicare.
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 available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to issue reimbursement for the bicycle (99199), delivery and set up (A9901), and the sales tax (S9999) provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthopedic services provided on November 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that a message from the plan was left on the wrong phone number. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available to 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 orthopedic services provided on November 11, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Contour Next test strips.

You asked the Plan to provide coverage for Contour Next test strips. You say that you prefer to use the requested brand of test strips. The Plan denied your request. The Plan says the requested brand is not covered under the Plan benefit. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.

The Plan is correct in this case. This is not a medical necessity issue. This is a contractual coverage issue. The rules say a Plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as benefit limitations, copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you will have zero-dollar cost share for diabetic supplies when you use the Plans contracted brands. The Plan is not obligated to waive the contractual rules if you choose to use a brand of test strips not covered by the Plan. Therefore, we decided that the Plan does not have to provide coverage for Contour Next test strips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care services provided by a participating provider on July 15, 2020, to July 20, 2020.
You asked the Plan to waive the copayment for emergency care service. You say that you should not have to pay for this. You say that it was due to incompetence. The Plan denied your request. The Plan says the correct copayments have been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 copayment for emergency care/in-network. You have been asked to pay a $120 copayment for emergency care service. The total amount you are being asked to pay is $480 ($120 x 4 visits = $480). Emergency care service falls within the emergency care/in-network 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 emergency care services provided by a participating provider on July 15, 2020, to July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the adjacent tissue transfer or rearrangement (14041) provided September 11, 2020.

You asked the Plan to waive the copayment for the adjacent tissue transfer or rearrangement services. You say that You do not think that this is right because they didn't charge you at the office and you just received a bill. The Plan denied your request. The Plan says this 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 $40 copay for each specialist visit. 

You have been asked to pay $40 copay for the adjacent tissue transfer or rearrangement services. The cosmetic and reconstructive procedures 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 the adjacent tissue transfer or rearrangement (14041) provided September 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam.
You asked the Plan to waive the copayment for the eye exam. You say that you had your annual diabetic exam and there should not be a copayment for this exam. The Plan denied your request. The Plan says the claim processed with the correct copayment.
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 $45 copayment for Medicare-covered eye exams, including diagnosis and treatment for diseases and conditions of the eye.
You have been asked to pay a $45 copayment the eye exam. The eye exam falls 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 waive the copayment for an eye exam.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the home ventilator and portable oxygen system rendered from July 30, 2020 to November 30, 2020.

You asked the Plan to waive the coinsurance for these services. You say that you told there would be no cost for the 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 in-network durable medical equipment.

Review of the file shows that you received a home ventilator and portable oxygen system from July 30, 2020 to November 30, 2020. You have been asked to pay a 20% coinsurance for these services. These services fall within the in-network durable medical equipment 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 home ventilator and portable oxygen system rendered from July 30, 2020 to November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 10, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered 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 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 the laboratory services provided on November 10, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health services provided October 5, 2020 to October 6, 2020.
You asked the Plan to pay for inpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid diagnosis code.
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 the inpatient mental health services are not supported in the medical record. Specifically, the diagnosis code submitted is not a valid diagnosis code for these services. The plan requested a correct claim. Based on this information, we decided that Medicare rules for coverage of inpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health services provided October 5, 2020 to October 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for an eye exam and eyeglasses provided on December 4, 2019.
You asked the Plan to pay an additional amount for the eye exam and eyeglasses. The Plan denied your request. The Plan says the claim processed correctly per your 2020 benefit plan for vision services.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan processed your claim correctly per your 2020 benefit plan for vision services. Therefore, we decided that the Plan does not have to pay an additional amount for an eye exam and eyeglasses provided on December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), the non-intravenous sedation (D9248), and the clinical crown lengthening (D4249).
You asked the Plan to pay for the dental services (D0180, D9248, D4249). You say that you have out-of-network coverage and therefore the plan should cover up to 100% of the allowable amount. The Plan denied your request. The Plan says the requested services are not covered under your plan's supplemental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Although the Plan provides reimbursement for services received out-of-network, the requested services are not covered by the plan under any circumstances. The Plan has a specific list of covered items and services, and D0180, D9248, and D4249 are not on that list. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), the non-intravenous sedation (D9248), and the clinical crown lengthening (D4249).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the home ventilator rental (E0466) provided on January 19, 2021.

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the item provided.

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 $0 copayment for compression stockings and a 20% coinsurance for all other durable medical items rendered by an in-network provider. 

You have been asked to pay $221.78 (Plan allowed amount of $1,108.91 x 20% coinsurance) for the durable medical equipment provided by an in-network provider. 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 home ventilator rental (E0466) provided on January 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the knee orthosis provided.
You asked the Plan to waive the cost share for the orthosis. You say that your doctor did not tell you the product was this expensive. The Plan denied your request. The Plan says the claim processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for durable medical equipment. You have been asked to pay a 20% coinsurance for the orthosis. The orthosis falls within the durable medical equipment 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 cost share for the knee orthosis.