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

We decided that the Plan does not have to pay fortest strips, lancets, control solution, and lancet device provided by the provider on August 2, 2019.You asked the Plan to pay fortest strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that The Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid and proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay fortest strips, lancets, control solution, and lancet device provided on August 2, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 11, 2019 by the out of network provider.
You asked the Plan to pay for the skilled nursing facility care. You say that the services were provided to the enrollee in good faith. You also say that since the enrollee was in a nursing facility, the provider was not responsible for obtaining the necessary authorizations. The Plan denied your request. The Plan says authorization was not obtained before the services were rendered to the enrollee. The Plan says the out of network nursing home referred the enrollee for the services. The Plan also says the services were not urgent or emergent.
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 nursing facility is not a network provider either. 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 subsequent nursing facility care provided on May 11, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient rehabilitation stay provided from April 25, 2019 through May 9, 2019.You asked the Plan to waive the copayment forthe inpatient rehabilitation stay. You say that you were informed that 7 days of hospital care and 21 days at a qualified care facility would be covered 100%. You say that you were not aware of a responsibility change when there is a transfer.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). The enrollee's contract with the Plan clearly says that enrollees must pay a $275 copayment each day for days 1 to 7 for Medicare-covered hospital care. $0 copayment for additional Medicare-covered days. For inpatient hospital care, the cost-sharing described above applies each time you are admitted to the hospital. A transfer to a separate facility type (such as an Inpatient Rehabilitation Hospital or Long Term Care Hospital) is considered a new admission.The enrollee has been asked to pay a $1,925 copayment for the inpatient rehabilitation stay. ($275/day x 7 days = $1,925). The inpatient rehabilitation stay falls within the "Inpatient Hospital Care" 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 forthe inpatient rehabilitation stay provided from April 25, 2019 through May 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99153) provided on January 24, 2019.You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documents submitted and claim form indicate this procedure was performed in a facility place of 22. Payment of this service is included in the payment to the facility.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 99153 is not supported in the record. Specifically, 99153 was billed with facility place of service 22. Additionally, this code is a technical component only code. This means that payment for 99153 is included in the payment to the facility and is not separately reimbursable.  Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided on January 24, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay formore than 30 minutes of hospital discharge day management services (99239) provided on April 30, 2019.You asked the Plan to pay for the hospital discharge day management. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the discharge summary does not support hospital discharge day management of more than 30 minutes was performed on the billed date of service.The Plan must follow Medicare rules. Medicare rules say that providersmust report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes.We find that CPT code 99239 is supported in the record. Specifically, the discharge summary indicates that more than 30 minutes if discharge day management services were rendered. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management. havebeen met. Therefore, we decided that the Plan has to pay for more than 30 minutes of hospital discharge day management services (99239) provided on April 30, 2019. 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 copayment for the office visit provided on August 21, 2019.You asked the Plan to waive the copayment for the office visit. You say that you are used to paying $10. You say that you should not be paying $35.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). Yourcontract with the Plan clearly says that you must pay a $35 copayment per visit for Medicare-covered specialty care services.You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the provider is a specialist. 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 office visit provided on August 21, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cardioversion provided on July 30, 2019.You asked the Plan to waive the copayment for the cardioversion. You say that you were informed that your copayment would be $50.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 $200 for each Medicare-covered in-network outpatient hospital facility visit.You have been asked to pay a $200 copayment for the cardio version. The cardio version 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 the cardio version provided on July 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services provided to the enrollee from July 31, 2019 to August 7, 2018.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says this code is not valid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for home infusion therapy services provided to the enrollee from July 31, 2019 to August 7, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on May 9, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 May 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on August 11, 2019 through August 18, 2019.You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration as S9328 is a valid code per CMS. The Plan denied your request. The Plan says procedure code S9328 has a status code of I which is not valid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S9328 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, S9328 has a status indicator of, "I." This means that S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on August 11, 2019 through August 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on May 20, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says HCPCS G0482 remains not supported.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on May 20, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on July 24, 2019 by out of network (OON) provider.You asked the Plan to pay for the OON psychotherapy services. You say that the enrollee has seen improvement since starting this care and it would be counterproductive to change treatment at this time.The Plan denied your request. The Plan says the enrollee received this non-emergency care without a referral or authorization from the plan. OON services are not covered as there are network providers able to furnish this psychological care.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 psychotherapy services provided on July 24, 2019 by out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on March 11, 2019 to April 5, 2019 by an out of network provider.You asked the Plan to pay foroffice services. You say that at the time of service the provider told you they were in-network with the Plan.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and you could have received services within the Plan's network.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 March 11, 2019 to April 5, 2019.Your complaint regarding receiving inaccurate information about this provider's network status is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the health plan for more information about your grievance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 8, 2019 by the out of network provider.You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says the services were not urgent or emergent.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 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 office visit provided on May 8, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe acute inpatient hospital care provided from November 4, 2018 to November 6, 2018.You asked the Planto pay foracute inpatient hospital care. You say that the inpatient admission was warranted due to the enrollee's condition.The Plandenied your request. The Plansaysthe enrollee was stable on admission and there was no need for more than two midnights of hospital care.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was admitted on 11/4/18 for evaluation of pain and swelling around a implanted pain pump in low back. Imaging at an outside hospital showed a collection of fluid in the tender area. He was evaluated on 11/5/18 by neurosurgery and was diagnosed with a pseudomeningomyelocele. There was no active infection. Pain was controlled with oral medication and oral Diamox was recommended going forward to reduce overall fluid accumulation. After the neurosurgical evaluation on 11/5/18, the enrollee was stable for discharge. It was clear at this point in time that there was no acute infection and that ongoing care could be safely provided in the outpatient setting. 
The record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plandoes not haveto pay forthe acute inpatient hospital care provided from November 4, 2018 to November 6, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330), and the consultation (D9310) provided by the dentist, on August 8, 2019.
You asked the Plan to pay for the dental services. You say that the Plan representative did not inform you that the rider only covered $1,000 per fiscal year. The Plan denied your request. The Plan says the annual maximum benefit of $1,000 has been exceeded. The Plan says the annual maximum benefit was reached with the processing of the claim for services you received on July 29, 2019.
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 and the services you received are covered services, the annual maximum benefit has been exceeded. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330), and the consultation (D9310) provided by the DDS, on August 8, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a chest x-ray (71045) provided by on August 27, 2019.You asked the Plan to pay for the chest x-ray. You say that the member had multiple exams on the same date of service. The Plan denied your request. The Plan says that the services are duplicate to another claim.The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.We find that CPT code 71045 is supported in the record. Specifically, the submitted documentation shows that there were two separate x-rays performed by different providers. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have been met. Therefore, we decided that the Plan has to pay for a chest x-ray (71045) provided by on August 27, 2019. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic visit, the electrocardiogram, and the laboratory services provided on April 19, 2019 by the out of network provider.
You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee self-directed for the services. The Plan also says the services can be provided in network.
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 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 outpatient clinic visit, the electrocardiogram, and the laboratory services provided on April 19, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe resin-based filling (D2331) on tooth #25 provided by the provider on August 6, 2019.You asked the Plan to pay forthe filling. You say that the plan should be responsible for payment because you needed to fix your tooth because it was an emergency, not a luxury. The Plan denied your request. The Plan says the service is 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 fillingis not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay forthe resin-based filling (D2331) on tooth #25 provided on August 6, 2019.