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

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on February 19, 2021.
You asked the Plan to pay for the home visit. You say that you are resubmitting the claim with documentation to support the billed codes. You say that the claim should be reprocessed for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and 
pre-approved care.
The requested 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 home visit provided by an out-of-network
provider on February 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and coinsurance for inpatient hospital services, outpatient diagnostic services and specialist services provided from January 3, 2021, to February 3, 2021.

You asked the Plan to waive the deductible and coinsurance for inpatient hospital services, outpatient diagnostic services and specialist services. You say that you feel that the charges are not accurate. 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. Your contract with the Plan says that there is a $110 deductible. Your contract with the Plan also clearly says that you must pay 15% coinsurance for inpatient hospital care, outpatient diagnostic tests and therapeutic services and supplies and physician/practitioner services, including doctor's office visits.

The record shows that you received inpatient hospital services, outpatient diagnostic services and specialist services from January 3, 2021, to February 3, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.

The total amount you owe is: $348.24.

The item or service you asked the Plan to waive the deductible for falls within the benefit categories: inpatient hospital care, outpatient diagnostic tests and therapeutic services and supplies and physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $110 deductible and 15% coinsurance for inpatient hospital care, outpatient diagnostic tests and therapeutic services and supplies and physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time inpatient hospital services, outpatient diagnostic services and specialist services were received on January 3, 2021 to February 3, 2021. Therefore, we decided that the Plan does not have to waive the deductible and coinsurance for inpatient hospital services, outpatient diagnostic services and specialist services provided from January 3, 2021, to February 3, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator provided on May 26, 2020.
You asked the Plan to pay for the neuromuscular stimulator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed do not support the item billed.
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 does not contain a valid proof of delivery for the supplies provided in this case. Review of the file
shows that the submitted invoice indicates the item was shipping April 30, 2020 and delivered on May 5, 2020;
however, the billed date of service is May 26, 2020. The record shows that the Plan made several attempts to
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay
for the neuromuscular stimulator provided on May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided by a chiropractor on October 19, 2020.
You asked the Plan to pay for office visit. You say that you were charged more than the out-of-pocket maximum amount for 2020, so should be reimbursed this amount. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is not covered by Medicare or the Plan when performed by a chiropractor.
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 service at issue is not manual manipulation of the spine. Because this service is not covered, it does not apply to the maximum out-of-pocket amount for the year. Therefore, we decided that the Plan does not have to pay for an office visit provided by a chiropractor on October 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the vertiflex device is contraindicated for you.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. High failure rates have been reported with similar devices. More research is needed to show safety and efficacy of the device. Our physician reviewer found that your condition does not meet criteria for coverage of these services. 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve the Vertiflex Superion Interspinous device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 3, 2020.

You asked the Plan to pay for the services. 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 had network providers available who could have provided 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 services provided by an out-of-network provider on April 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan
denied your request. The Plan says criteria for admission to the IRF setting have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of the your nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require
physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. There is not a reasonable expectation
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on March 2, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the testing services. You say that you were not aware of the requirement of obtaining a prior authorization. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the lab 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 drug testing services provided on March 2, 2021 by an out of network
(OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities (97530) provided on June 2, 2020.

You asked the Plan to pay for therapeutic activities. You say that this should be processed as an in-network service. The Plan denied your request. The Plan says this was not billed correctly.

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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.

We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that this service was provided in a home health setting. There is a more appropriate code for this service. Based on this information, we decided that Medicare rules for coverage of therapeutic activities have not been met.

Therefore, we decided that the Plan does not have to pay for therapeutic activities (97530) provided on June 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for inpatient hospital care provided on February 17, 2021, through February 19, 2021.

You asked the Plan to waive the co-payment for inpatient hospital care. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 co-payment each day one through five for inpatient hospital care.

You have been asked to pay a $300 co-payment each day one through five for inpatient hospital care. inpatient hospital care falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan ($350 x 2days = $700). 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 co-payment for inpatient hospital care provided on February 17, 2021, through February 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the lab services provided to you on March 5, 2021.

You asked the Plan to waive the co-payment. The Plan denied your request. The Plan says you are responsible for the co-payment.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 co-payment for lab services provided at a freestanding laboratory.

Review of the file shows that you were provided lab services at a freestanding facility on March 5, 2021. You have been asked to pay a $15 co-payment for the lab services. The lab services 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 lab services provided to you on March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an E2300 seat elevation system and K0108
(bag hooks) to be used with a power wheelchair for the enrollee.

You asked the Plan to provide coverage for these accessories. You say that these accessories are medically
necessary for the enrollee's use with a power wheelchair. The Plan denied your request. The Plan says neither
of these accessories are covered by Medicare.

Maximus upheld the Plans denial on the E2300 seat elevation system but neglected to mention the K0108 bag hooks. The Plan requested a reopen and asked Maximus to review the bag hooks as well.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Bag hooks for a wheelchair or any other piece of durable medical equipment are considered a convenience item and are not covered by Medicare. Bag hooks do not serve a purpose that is primarily medical in nature. Bag hooks are available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to provide coverage for an E2300 seat elevation system and K0108 (bag hooks) to be used with a power wheelchair for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

You were admitted for surgical treatment of sacral and pubic fractures after a fall. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on June 27, 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 code 97110 is 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. 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 physical therapy services rendered on June 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the electrocardiogram, routine ECG with at
least 12 leads (93000) provided January 29, 2021.
You asked the Plan to waive the co-payment for the diagnostic service. You say that you were not properly
informed by the provider that aside from the office visit copay of $35 that you paid upfront that you will also
be charged a copay for the electrocardiogram. The Plan denied your request. The Plan says this claim was
processed with the correct co-payment applied per the Evidence of Coverage
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20
co-payment for Medicare covered non-radiological diagnostic services.
You have been asked to pay $13.58 co-payment for the diagnostic service. Since the allowed amount of $13.58
is less than the $20 co-payment amount, you are responsible for the lesser amount. The diagnostic service falls
within the Outpatient Diagnostic Tests and Therapeutic services and Supplies benefit category. This means that
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the co-payment for the electrocardiogram, routine ECG with at least 12 leads (93000)
provided January 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery cover (K0108).

You asked the Plan to pre-approve a battery cover. You say that the item should be covered. The Plan denied your request. The Plan says the battery cover does not serve a medical function and does not meet the Medicare definition of durable medical equipment.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a battery cover (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dialysis, injections and Hepatitis B
vaccine provided from November 1, 2020, through November 30, 2020.

You asked the Plan to waive the coinsurance for the dialysis, injections and Hepatitis B vaccine. You say that
he was unjustly getting the bill for dialysis treatments because he was automatically put back on his old Plan.
You say that your father should not have to pay. The Plan denied your request. The Plan says the coinsurance
applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
co-payments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay 20% coinsurance for each Medicare-covered renal dialysis performed by a plan provider within the
plan service area and 20% coinsurance for Part B injectable drugs that aren't self-administered

The enrollee has been asked to pay a total of $964.57 for the dialysis, injections and Hepatitis B vaccine.

The dialysis falls within the "Services to treat kidney disease" benefit category. The injections and Hepatitis B
vaccine fall within the "Medicare Part B prescription drugs" 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 coinsurance for the dialysis, injections and Hepatitis B vaccine provided from November 1,
2020, through November 30, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 4, 2020.

You asked the Plan to pay for the laboratory services. You say that the test requested for this enrollee was medically necessary to assist in the treatment, prognosis, and diagnosis of their cancer. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

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 for the laboratory services provided on November 4, 2020.