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

We decided that the Plan does not have to pay forthe ankle foot orthoses provided on February 28, 2019.You asked the Plan to pay forthe ankle foot orthoses (L1971). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says criteria for the orthoses have not been met.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 ankle foot orthoses (L1971). Our physician reviewer foundthe enrollee's chief complaint was ankle pain. The documentation in the case file does not support that the requested ankle/foot orthoses were medically reasonable and necessary for the enrollee in this case, according to the criteria established by the LCD. A physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the ankle/foot orthoses were medically reasonable and necessary in this case, as there is no documentation of a credible physical examination of the ankles and feet.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 ankle foot orthoses(L1971) have not been met.Therefore, we decided that the Plan does not have to pay forthe ankle foot orthoses provided on February 28, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pay forhome health services provided to the enrollee from January 5, 2019 to January 31, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis is not a network provider.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 rendering 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 Plandoes not haveto pay forhome health services provided to the enrollee from January 5, 2019 to January 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmic biometry provided on July 24, 2019.
You asked the Plan to waive the copayment for ophthalmic biometry. You say that you were told you would only be charged a copayment if you saw a doctor, not a nurse. The Plan denied your request. The Plan says this service processed 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 Medicare-covered exams. You have been asked to pay a $35 copayment for ophthalmic biometry. Ophthalmic biometry falls within the Medicare-covered exams 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 ophthalmic biometry provided on July 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete set of radiographic images (D0210) provided on September 23, 2019.
You asked the Plan to pay for the dental services. You say that you received bad dentistry from the provider. You say that You also say that due to this, the x-rays by the provider should be covered. The Plan denied your request. The Plan says the frequency limit for the complete series of radiographic images has been exceeded. The Plan says that 1 complete series of radiographic images is covered every 3 calendar years.
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 complete series of radiographic images is listed as a covered service, the frequency limit for this services has been exceeded. The record shows that you last received this service on January 9, 2019. Therefore, we decided that the Plan does not have to pay for the complete set of radiographic images (D0210) provided on September 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ALS routine disposable supplies (A0398) capnography (A0999) and rythmEKG (93041) provided on May 13, 2019.You asked the Plan to pay for the ambulance services. You say that the medical records should support the medical necessity for the services in dispute.The Plan denied your request. The Plan says payment for these services is included in the transportation fee. Medicare does not allow separate billing of these supplies.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, we have confirmed that code the ambulance services has a bundled relationship with code A0427 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay for ALS routine disposable supplies (A0398) capnography (A0999) and rythm EKG (93041) provided on May 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 26, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the office visit. We decided that the Plan does not have to waive the copayment for the office visit.
You asked the Plan to waive the copayment for the office visit. You say that you are appealing this copayment. The Plan says that you have been charged the correct cost sharing amount.
We decided that the Plan has to reduce the copayment for the office visit.
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). The record shows that the provider is a Family Nurse Practitioner.
The Plan says that you must pay a $50 for the office visit. Based on the plan contract, however, you cannot be asked to pay more than a $5 copayment for the office visit. Therefore, we decided that the Plan has to reduce the copayment for the office visit from a $50 copayment to a $5 copayment.
We also decided that the Plan does not have to waive the copayment for the office visit.
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 $5 copayment for the office visit. Therefore, we decided that the Plan does not have to waive the copayment for the office visit.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on June 19, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You say that you are unsure why you have to pay the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $110 copayment for the emergency room visit. The emergency room 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 for the emergency room visit provided on June 19, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments foroutpatient rehabilitation services provided at the provider from June 3, 2019 to July 12, 2019.You asked the Plan to waive the copayments foroutpatient rehabilitation services. You say that you were not told that you would owe a copayment per each visit.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 $20 copayment for outpatient rehabilitation services. You received outpatient rehabilitation services from June 3, 2019 to July 12, 2019 for a total of 12 visits. Therefore, you are responsible to pay a $20 copayment per each visit. The total amount you owe is: $20 (copayment) x 12 (PT visits) = $240.00.You have been asked to pay the total copayment amount of $240.00 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 copayments foroutpatient rehabilitation services provided.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-covered ambulance mileage (A0888) provided on March 26, 2019.You asked the Plan to pay for the non-covered ambulance mileage. You say that this was incorrectly coded as a non-emergency The Plan denied your request. The Plan says the ambulance trip notes states that the enrollee requested to go to this hospital because his doctors are there instead of going to the nearest hospital.The Plan must follow Medicare rules. The rules say that Medicare pays for air or ground ambulance services only if the enrollee's medical condition is such that transportation by means other than an ambulance would not be appropriate.  The rules say that Medicare only pays for air or ground transport to the nearest facility that meets the enrollee's medical needs.  The plan had paid for the ALS emergency ambulance services and ground mileage up to the nearest facility that was able to provide care.  The enrollee is responsible for  the mileage over the nearest facility.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-covered ambulance mileage have not been met.Therefore, we decided that the Plan does not have to pay for non-covered ambulance mileage (A0888) provided on March 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 14, 2019.You asked the Plan to pay for the physician's services. 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 physician's services provided on August 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the abdomen and pelvis (74177), colonoscopy (45380), and hepatobiliary system imaging (HIDA) scan provided from August 6, 2019 to August 26, 2019.You asked the Plan to waive the copayment for the CT scan of the abdomen and pelvis, colonoscopy, and HIDA scan. You say that the copayments should be waived since you have never been billed a copayment for a CT scan before and you were told by the provider you would not be billed a copayment for the colonoscopy.The Plan denied your request. The Plan says based on Medicare billing criteria, the claims were billed 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 $250 copayment for diagnostic radiology services. You have been asked to pay $750 for the CT scan of the abdomen and pelvis, colonoscopy, and HIDA scan. $250 for each diagnostic radiology service equals $750. 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 computed tomography (CT) scan of the abdomen and pelvis (74177), colonoscopy (45380), and hepatobiliary system imaging (HIDA) scan provided from August 6, 2019 to August 26, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the critical care services provided on May 28, 2019.You asked the Plan to pay for the critical care services. You say that the services were billed correctly and should be paid.The Plan denied your request. The Plan says that it is not appropriate to report unspecified, or left and right diagnosis codes when a more specific (e.g. bilateral) code is available; therefore the reported service has been denied.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. In this case, the Plan's denial is that one of the billed diagnosis codes does not adequately specify laterality. Review of the claim shows that none of the billed diagnosis codes have reported unspecified laterality. We are not able to confirm the denial rationale based on incorrect diagnosis coding. As such, we find that this denial of payment is not supported.Therefore, we decided that the Plan has to pay for the critical care services provided on May 28, 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/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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora SNF stay provided from March 22, 2019 to April 22, 2019.You asked the Plan to waive the copayment fora SNF stay. You say that the enrollee had ulcers related to a previous SNF stay and you feel that the charges should be waived.The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). the enrollees contract with the Plan clearly says that enrollees must pay a $0 copayment per day for days 1-20 and a $100 copayment per day for days 21-100 for SNF care The enrollee had a SNF stay from March 22, 2019 to April 22, 2019. The record shows that the enrollee had a previous SNF stay for a total of 21 days. Therefore, the enrollee is responsible to pay a $100 copayment for days 22-52(March 22, 2019 to April 21, 2019). $100 (copayment) x 31 (SNF days) = $3,100.00.the enrollee has been asked to pay the total copayment amount of $3,100.00 for a SNF stay. ASNF stay falls within the SNF 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 fora SNF stay provided from March 22, 2019 to April 22, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided to the enrollee on August 3, 2019.You asked the Plan to waive the copay for the ambulance transport. You say that intra hospital transfers should be the responsibility of the hospital.The Plan denied your request. The Plan says that the member is responsible for the copay.The rules say a plan must disclose to its enrollees inclear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). the enrollees contract with the Plan clearly says that enrollees must pay a $265 copay for each covered, one-way ambulance trip by ground or water. the enrollee has been asked to pay a $265 copay for the ambulance transport. The ambulance transport falls within the -way ambulance trip by ground or water 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 copay for the ambulance transport provided to the enrollee on August3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased on March 11, 2019.You asked the Plan to pay for the eyeglasses. You say that it should not matter where you get your glasses from when you paid for them in full. You have always received your refund.The Plan denied your request. The Plan says eyewear purchased from an out of network provider will not be covered.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. The Plan covers these services when The plan will provide a $150 allowance every 24 months for eyewear purchased from a plan optical facility.We looked atthe file and the Plan's rules. For covered Vision care and eyewear services you must go to an in-network provider. The practice is not an in-network provider. Based on this information, we decided that the 
Plan's rules for coverage of the eyeglasses have not been met.Therefore, we decided that the Plan does not have to pay forthe eyeglasses purchased from the practice on March 11, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fo rthe medical services provided to the enrollee by an out-of-network provider on June 6, 2019.You asked the Plan to pay for the services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not authorized. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on June 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (97110, 97140, and 98943) provided on April 22, 2019.You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says these services are not covered.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe chiropractic services (97110, 97140, and 98943) provided to the enrollee on April 22, 2019.