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

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425, A0428) received on March 24, March 25, March 26, March 29, March 30, March 31, and April 1, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were unaware of the cost sharing obligation for these rides. The Plan denied your request. The Plan says the correct cot share applied to the claims.
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 $200 copayment per one-way trip for emergency and non-emergency ambulance services for Ambulance Services. You have been asked to pay a $2800 in copayments (a $200 copayment per one-way trip for emergency and
non-emergency ambulance services) for the ambulance transportation. You received 14 separate rides across seven days. The ambulance transportation falls within the Ambulance 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 ambulance transportation (A0425, A0428) received on March 24, March 25, March 26, March 29, March 30, March 31, and April 1, 2021
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on February 11, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, we decided that the Plan has to pay for the laboratory services provided on February 11, 2021.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (power mobility device).
You asked the Plan to pre-approve power wheelchair. You say that you need a power wheelchair to move around your house and live your life. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because there is no documentation of an evaluation of your home to see if it can accommodate a power wheelchair or if you can transfer from or operate a power wheelchair without an accident.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power wheelchair. Our reviewer says that you do not meet the Medicare criteria for the requested power mobility device. Our physician reviewer found there is no documentation that you have a personal mobility deficit that impairs participation in mobility-
related activities of daily living such as toileting, feeding, grooming, and bathing in customary locations within
the home. There is no documentation that your mobility deficit cannot be helped by the use of a cane, walker,
or manual wheelchair. There is no documentation that you can safely operate the requested power wheelchair.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of power wheelchair have not been met. Therefore, we decided that the Plan does
not have to pre-approve a power wheelchair (power mobility device).
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does 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 this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for an office visit provided by Pain Recovery Solutions, PC on April 16, 2021.
You asked the Plan to waive the coinsurance for an office visit. You say that you do not agree with these charges. The Plan denied your request. The Plan says that the correct coinsurance has been applied.
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 enrollees must pay a $0 copayment for physician/practitioner services/in-network. The Plan says you must pay a 20% coinsurance for an office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for an office visit. Therefore, we decided that the Plan has to waive the coinsurance for an office visit provided by Pain Recovery Solutions, PC on April 16, 2021.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services rendered on September 14, 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 97530 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 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 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 occupational therapy services rendered on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy, molar tooth (excluding final restoration) (D3330) received April 15, 2021 from the Medicare opt-out provider.
You asked the Plan to pay for the endodontic therapy. You say that there was not a network provider within reasonable distance of your home. The Plan denied your request. The Plan says if you receive services from a dentist that has affirmatively opted not to participate with Medicare, the Plan will be unable to make any payments to either you or your dentist and you will be responsible for all costs.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit when they are received from a provider who has affirmatively opted out of Medicare. The Plan has submitted evidence that this provider has opted out of Original Medicare. Per the Plan contract, payment cannot be made to either you or the provider for the services received April 15, 2021. Therefore, we decided that the Plan does not have to pay for the endodontic therapy, molar tooth (excluding final restoration) (D3330) received April 15, 2021 from the Medicare opt-out provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital care provided from September 13, 2020, through October 7, 2020.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.
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 $375 copayment each day for days 1 to 5 for Medicare covered hospital care rendered by an in-network provider.
Additionally, you pay a $500 copayment each day for days 1 to 20 for Medicare-covered hospital care rendered by an out of network provider. . You have been asked to pay $3,375 ($375 copayment x 4 days=$1500) for the inpatient hospital care provided from September 13, 2020 to September 18, 2020 and ($375 copayment x 5 days=$1,875) for the inpatient hospital care provided from October 2, 2020, through October 7, 2020. The inpatient hospital care has been covered by the Plan at an in-network benefit level. 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 for the inpatient hospital care provided from September 13, 2020, through October 7, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee did have documented skilled therapy needs. Daily skilled services were reasonably required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition at her new weight bearing level. The enrollee's care needs, as a practical matter, could not be provided at a lower level of 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy 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 SNF care have not been met. Specifically, medically necessary services can be provided at a lower level of care. This means SNF care is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing or skilled therapy needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Specifically, medically necessary services can be provided at a lower level of care. This means SNF care is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for a stress test, single-photon emission computed tomography (SPECT) test, and technetium imaging supplies provided on September 8, 2020.
You asked the Plan to waive the cost-sharing for stress test, SPECT test, and imaging supplies. You say that under your previous plan you only had one copayment per claim, and you do not understand why the Plan billed you 3 different cost-sharing amounts. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.
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 $30 copayment for stress test, $155 copayment for SPECT test, and 20% coinsurance for imaging supplies. The allowed amount of the imaging supplies is $170, resulting in a coinsurance amount of $34. Your total cost-sharing amount is therefore $219. You have been asked to pay $30 copayment for stress test, $155 copayment for SPECT test, and 20% coinsurance for imaging supplies. Stress test, SPECT test, and imaging supplies 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 cost-sharing for a stress test, single-photon emission computed tomography (SPECT) test, and technetium imaging supplies provided on September 8, 2020.
Your complaint regarding the amount of time it took the Plan to make a final decision is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), periapical first radiographic image (D0220), and periapical each additional image (D0230) provided March 24, 2021.
You asked the Plan to pay for the panoramic x-rays and periapical x-rays. You say that there was miscommunication about coverage and you cannot afford the cost. The Plan denied your request. The Plan says that these services were not pre-approved and are not covered under your dental benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
panoramic radiographic image (D0330), periapical first radiographic image (D0220), and periapical each
additional image (D0230) provided March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on January 28, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on January 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily basis or on an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Specifically, medically necessary services can be provided at a lower level of care. This means that SNF care is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive cardiovascular panel (81407, 81479, 81405, 81406, 81286, 81408, 81404) provided on October 23, 2020.
You asked the Plan to pay for a comprehensive cardiovascular panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive cardiovascular panel have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive cardiovascular panel (81407, 81479, 81405, 81406, 81286, 81408, 81404) provided on October 23, 2020.