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

We decided that the Plan does not have to waive the copayment for an X-ray provided on July 26, 2019. 
 
You asked the Plan to waive the copayment for an X-ray. You say that you should only owe a $10 copayment for X-rays. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for X-rays and other radiology services billed the hospital. 
 
You received an X-ray at an outpatient hospital facility. Therefore, you are responsible to pay the $100 copayment.   
 
You have been asked to pay a $100 copayment for an X-ray. An X-ray falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an X-ray provided on July 26, 2019.  
 
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to the enrolle on November 7, 2019 to November 11, 2019. 
 
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 that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee on November 7, 2019 to November 11, 2019.  
 
Benefits for these services 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a radiological examination of the spine provided on December 7, 2018.
You asked the Plan to pay for the radiological examination of the spine. You say that you asked the doctor, as well as his staff, if you needed any approvals or authorizations and was told all you needed was the one form. You say that you told the lady at the front desk that you have always been confused with the referrals and authorizations and that you were not sure if you had all of the appropriate paperwork. You say she told you not to worry and to have a seat and that she would check in the system to be sure everything was in order and she said everything was fine and sent you back to get the x-ray. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 radiological examination of the spine provided on December 7, 2018.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Insertion of a Central Venous Access Device (76937, 36556) provided May 11, 2019.You asked the Plan to pay forthe hospital services. You say that the services were medically necessary.The Plandenied your request. The Plan says services must be billed to original Medicare as the enrollee had elected to use their hospice benefit.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 forthe Insertion of a Central Venous Access Device (76937, 36556) provided May 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea high frequency chest wall oscillation device (HFCWOD).You asked the Plan to pre-approvea HFCWOD. You say that please do not base the decision on just diagnosis alone, rather consider the multitude of respiratory symptoms and the critical need to effectively treat her.The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval.The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 a HFCWOD. Our reviewer says that the request for the HFCWOD is not medically necessary for this enrollee. Our physician reviewer found the enrollee has chronic bronchitis, a form of COPD. She does not have a coverable diagnosis of bronchiectasis, cystic fibrosis, or a specific generalized neuromuscular disease. HFCWOD has not been shown to be beneficial in COPD/chronic bronchitis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a HFCWOD have not been met.Therefore, we decided that the Plan does not have to pre-approvea high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 15, 2019 by out of network provider,.You asked the Plan to pay forpractitioner visit. You say that the facility requested this provider to see the enrollee, therefore medical necessity is pre-established for this service.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring facility Cane Creek Nursing Facility is also out-of-network with the Plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on August 15, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) tertiary care provider.You asked the Plan to pre-approve the out-of-network tertiary level of care. You say that the provider the enrollee was referred to is more than 15 miles from her home. You say that the in-network facility is sub-par compared to the provider facility being requested.The Plan denied your request. The Plan says provider is an out-of-network provider. The Plan says that the enrollee's care can be safely rendered in-network at The Oncology Institute.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The provider at issue in this case is not a network provider with the Plan. 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 out-of-network tertiary level of care. Our reviewer says that the criteria for out-of-network care have not been met. Our physician reviewer found the Plan's denial is medically justified in that they are offering adequate care to meet the enrollee's medical needs through referral to an in-network provider. There is nothing unique about the enrollee's condition that would make it medically necessary to see the requested out-of-network provider. The plan has shown that they have in-network providers who meet the Standards of Care required for treatment of the enrollee's condition.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 out-of-network tertiary level of care have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the out-of-network tertiary level of care.Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) tertiary care provider.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the emergency ambulance services (A0429) and ground mileage (A0425) provided by on June 3, 2019.
You asked the Plan to pay for the ambulance services. You say that you are requesting reconsideration of payment. The Plan denied your request. The Plan says that the Medicare criteria for ambulance services have not been met.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation provided, transportation via ambulance to the ED was medically necessary. The enrollee did require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. Transportation could not have been provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. 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 ambulance services have been met. Therefore, we decided that the Plan has to pay for the emergency ambulance services (A0429) and ground mileage (A0425) provided on June 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical supplies to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe medical supplies provided by an OON provider. You say that you have been with provider for quite some time. You say that you trust this company and that they always make sure you have your supplies on time. You say that you do not want to risk any delays, or your health, especially now with the virus.The Plan denied your request. The Plan says your condition would benefit from transition of care planning. The Plan says that to facility a smooth transition of care, 1-months' worth of colostomy and urostomy supplies have been authorized with the OON provider. The plan says that after this transition of care planning, further use of the OON provider is not justified based on the coverage criteria.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe medical supplies to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you had a medical emergency due to
critically low blood glucose levels. You say that 911 was called and the responders started an IV to stabilize
you. You stated that there was no need for transportation to the hospital and at the time you were unaware that
you would be charged if you were not transported. You say that since you were not notified of this on the date
of service, the charges should not be your responsibility. 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 October 12, 2019. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided on December 6,
2019.
You asked the Plan to waive the copayment for vision services. You say that you were scheduled for routine
services and would not have went to the visit if you knew you would receive medical 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 a $45
copayment for vision services.
You have been asked to pay a $45 copayment for vision services. Vision services fall within the vision services
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 vision services provided on
December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy services rendered on January 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 procedure codes 96413, 96417, and 96375 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 96413 is chemotherapy administration, intravenous
infusion technique; up to 1 hour, single or initial substance/drug. The definition of code 96417 is chemotherapy
administration, intravenous infusion technique; each additional sequential infusion (different substance/drug),
up to 1 hour (List separately in addition to code for primary procedure). The definition of code 96375 is
therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential
intravenous push of a new substance/drug (List separately in addition to code for primary procedure).
We find that CPT codes 96413, 96417, and 96375 are not supported in the medical record. Specifically, there is
no documentation of the start and stop time indicating chemotherapy administration to support code 96413.
Given that the primary code 96413 is not supported, add-on codes 96417 and 96375 are also not supported.
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 chemotherapy services rendered on January
29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
January 9, 2020.
You asked the Plan to pay for the assembly and operation of a pump. You say that you would like
reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in
the operating room during the length of the procedure. The Plan denied your request. The Plan says payment
for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier
other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the assembly and operation of a pump have not been met. Specifically, payment for this service is
included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore,
we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
January 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 16,
2018 to September 25, 2018.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled
Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that the enrollee received 100 days of SNF care during the benefit period from May 27, 2018 to
September 15, 2018. The Plan has covered 100 days of SNF care.
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided
that the Plan does not have to pay for the skilled nursing services provided from September 16, 2018 to
September 25, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on December 18, 2019.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit received on February 4, 2020.
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The
Plan says the service is related to a Worker's Compensation injury.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. The plan would need to have
documentation from worker's comp stating that they would not pay for these services. As the secondary insurer,
the Plan cannot be held responsible for the visit until the primary insurer has denied the claim for these
services. Therefore, we decided that the Plan does not have to pay for an office visit received on February 4,
2020.