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

We decided that the Plan does not have to pay for the ambulance services provided on September 1, 2020. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor's office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 5, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the radiology services (72040 and 72070). You say that you would like 
reconsideration because you were referred to this radiologist. The Plan denied your request. The Plan says you 
must use network providers for your medical care and services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 5, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and gingival irrigation (D4921) provided on September 22, 2020.

You asked the Plan to pay for the periodontal maintenance and gingival irrigation. You say that you were not aware you were being billed for anything other than a routine cleaning. The Plan denied your request. The Plan says the services you received are not a covered 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. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) and gingival irrigation (D4921) provided on September 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the records provided support the need for care in an IRF.The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in another setting.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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for weakness and an infection in his arm near his dialysis fistula. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee 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-approveacute inpatient rehabilitation facility (IRF)admission and services
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on June 4, 
2020 and July 13, 2020. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you asked for the blood draws 
to be done at your residence. You say that insurance should be pay the bill. The Plan denied your request. The 
Plan says the copayments 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 $0 
copayment for Medicare-covered lab services at a freestanding provider or $50 copayment at an outpatient 
hospital setting.  
 
You have been asked to pay a total of $81.80 for the laboratory services.  
 
Date of Service Service Allowed Amount Standard Copayment Member Liability 
June 4, 2020 Laboratory Test $4.60 $50 $4.60 
June 4, 2020 Laboratory Tests $27.20 $50 $27.20 
July 13, 2020 Laboratory Tests $63 $50 $50 
TOTAL:    $81.80 
 
  
 
 
Laboratory services fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 
benefit category. The records show that the laboratory services were billed by the hospital. 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 laboratory services provided on June 4, 2020 and July 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forto pay for transportation services provided to the enrollee on October 10, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the first-listed primary diagnosis code for this claim is W88.0XXS (exposure to x-rays, sequela). This code is classified as an "external cause of morbidity" and can be found in Chapter 20 of the ICD-10 manual. In this chapter it states: "the external causes of morbidity codes should never be sequenced as the first-listed or principal diagnosis. This edit applied as intended and will remain in place to ensure the most appropriate codes are being billed." The Plan states Medicare billing criteria are not met. 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, this claim cannot be paid as billed due to an issue with the primary diagnosis code reported. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forto pay for transportation services provided to the enrollee on October 10, 2019
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by THE Medical Transport 
Services, Inc. on March 19, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you did not request for this service. The 
Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 19, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by THE Medical 
Transport Services, Inc. on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the penile injection provided on June 29, 
2020. 
 
You asked the Plan to waive the copayment for the penile injection. You say that you were informed 
copayments were being waived. 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 specialist visit. Covered services include medically necessary medical care or surgery 
services furnished in a physician?s office, certified ambulatory surgical center, hospital outpatient department, 
or any other location.  
 
You have been asked to pay a $35 copayment for the penile injection. The penile injection falls within the 
"Physician/Practitioner services, including doctors office visits" benefit category. The Plan says that only 
copayments for primary care office visits and specialist office visits are being waived. Additional charges may 
apply for tests, procedures or other services performed at the office. A surgical injection was billed, which still 
applies a copayment.  
 
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 penile injection provided on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy of the breast (19081) performed. 
 
You asked the Plan to waive the copayment for a biopsy of the breast. You say that the provider told you there 
would be no charge. The Plan denied your request. The Plan says the correct copayment was 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 $395 
copayment for each visit for outpatient surgery.  
 
You have been asked to pay a $395 copayment for a biopsy of the breast. A biopsy of the breast 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 a biopsy of the breast 
(19081) performed.  
 
Your complaint about receiving erroneous or misleading information about your cost-sharing responsibility 
from your provider 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant /abutment supported removable denture 
(D6111) and replacement of replaceable part of semi-precision or precision attachment (D5867). 
 
You asked the Plan to pre-approve implant /abutment supported removable denture and replacement of 
replaceable part of semi-precision or precision attachment. You say that the services requested are medically 
necessary for your condition. The Plan denied your request. The Plan says the services are not covered by the 
supplemental dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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. Therefore, we decided that the Plan does not have to pre-approve 
implant /abutment supported removable denture (D6111) and replacement of replaceable part of semi-precision 
or precision attachment (D5867).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitoring device rendered from January 31, 2020 to 
February 29, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes.  
 
We looked at the file and Medicare rules. The provider submitted claims for procedure code A9279. This code 
has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not 
have to pay for the monitoring device rendered from January 31, 2020 to February 29, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvean expandable controller (E2377, E2313, E2311).You asked the Plan to pre-approvean expandable controller. You say that this is medically necessary.The Plan denied your request. The Plan says that you can control the power options with their own switches.The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically necessary for the functions listed 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 an expandable controller. Our reviewer says that the requested items are medically necessary. Our physician reviewer found the documentation supports that the requested expandable controller is medically reasonable and necessary to operate 3 or more powered seating actuators through the drive control.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller have been met.Therefore, we decided that the Plan has to pre-approvean expandable controller (E2377, E2313, E2311).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/orsend 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia syringe. 
 
You asked the Plan to pre-approve Prolia syringe (J0897). You say that you want the enrollee to continue to 
use this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's 
Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prolia syringe.  
 
Benefits for Prolia syringe (J0897) may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxycodone Acetaminophen 10- 325 (56 tablets) provided. 
 
You asked the Plan to pay for oxycodone Acetaminophen 10- 325 (56 tablets). You say that the item should be 
covered. The Plan denied your request. The Plan says you do not have drug coverage with this Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for oxycodone Acetaminophen 10- 
325 (56 tablets) provided.  
 
Benefits for oxycodone Acetaminophen 10- 325 (56 tablets) may be available under Medicare Part D. Contact 
the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary rest home visit provided. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
prior authorization was not obtained by the provider or the facility. 
 
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 
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 a domiciliary rest home visit provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a pulse oximetry study (94762) provided September 3, 2020.
You asked the Plan to waive the copayment for the pulse oximetry study. You say that the copayment should be waived. 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 $10 copayment for Outpatient Diagnostic Tests. You have been asked to pay a $10 copayment for the pulse oximetry study. The pulse oximetry study falls within the Outpatient Diagnostic Tests 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 pulse oximetry study (94762) provided September 3, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency department visit on September 16, 2020.You asked the Plan to waive the copayment forthe emergency department visit. You say that it is not your fault the x-ray machine was not working at urgent care.The Plan denied your request. The Plan says you were charged this copayment 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 $110 copayment for Emergency Care. You have been asked to pay a $110 copayment for the emergency department visit. The emergency department visit falls within the Emergency 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 forthe emergency department visit on September 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory infectious agent detection panel rendered on 
July 23, 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 the testing is not covered. 
 
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. There is no documentation to support that the testing was necessary 
for the enrollee. 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 respiratory infectious agent 
detection panel rendered on July 23, 2020.  
 
Local Coverage Article (LCA) A57579 and Local Coverage Determination (LCD) L37764 referenced by the 
Plan are not valid for Part B Medicare in the state of Florida where the testing was performed and were not 
used in the MAXIMUS determination.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drugs provided from June 4, 2020, to June 5, 2020.You asked the Plan to pay forthe self-administered drugs. You say that the drugs should be covered.The Plan denied your request. The Plan says the drugs that you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs that you received are not covered under Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administereddrugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe self-administered drugs provided from June 4, 2020, to June 5, 2020.Benefits for the self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Surgery
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b).The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $350 copayment per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. You can find this information on page 94 of the Plan's 2020 EOC.