Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eyewear purchased on December 13, 2019.You asked the Plan to pay forthe eyewear. You say that your request is within the allowed amount.The Plandenied your request. The Plan says that coverage is limited to up to one pair of eyeglasses every year.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 one pair of eyeglasses (lenses and frames) every year.We looked at the file and the Plan's rules. The file indicates the Plan has already covered one pair of eyeglasses on February 13, 2019. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met.Therefore, we decided that the Plan does not have to pay forthe eyewear purchased on December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on October 21, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary The Plan denied your request. The Plan says criteria for the orthosis was not 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 lumbar-sacral orthosis (L0650). Our reviewer says that the orthosis was not medically necessary. Our physician reviewer found the enrollee's chief complaint was lower back pain, as well as pain located in the wrist left and wrist right. The available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible physical examination of the back. 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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on October 21, 2019.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for the home health services provided from October 1, 2019 to October 6, 2019.
You asked the Plan to pay for the home health services. You say that this should be paid because the Plan has approved these services to be rendered by this provider. The Plan denied your request. The Plan says that the claim cannot be paid because no RAP was ever submitted. Upon revealing that a RAP was in fact submitted, the Plan stated that it was not valid because more than one line item was reported.
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. The Plan denied this claim on the basis that no RAP was submitted. The original case file only contained the final claim on Type of Bill (TOB) 0327. The Plan did not mention or provide any indication that it had ever received any other billing for this episode of care. MAXIMUS requested additional information due to discrepancies with the dates provided by the Plan and it was found that, in fact, a RAP had been submitted on October 16, 2019, with TOB 0322, which denotes that the claim is a RAP. The Plan then indicated that this was not considered a RAP because more than one line item was reported and only one is required. However, the rules as cited above clearly indicate that a RAP can optionally report more line items so considering this RAP invalid is not correct. Since the claim was denied due to no RAP being received, when a RAP was received, we find that the denial of payment of the claim at issue is not supported. Therefore, we decided that the Plan has to pay for the home health services provided from October 1, 2019 to October 6, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided by
December 27, 2019.
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the Plan
should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not
indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be
verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. There are no medical records supporting medical necessity for the
orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthoses (L1833)
and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have to pay
for the knee orthoses and suspension sleeves provided on December 27, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for planning services (CPT 77014) provided to the enrollee from October 18, 2019 to October 29, 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 that separate payment is not allowed for planning services billed within 14 days of treatment planning for the same condition.
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 77014 is "Computed tomography guidance for placement of radiation therapy fields." 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 services. Our reviewers says that the services at issue in this case were coded correctly. Our physician reviewer found CPT 77014 is bundled with CPT 77301 when billed on the same date of service as CPT 77301. In this case, CPT 77014 was not billed on the same date of service, and should be considered payable for the dates of service at issue in this case. CPT 77031 was performed on October 16, 2019, prior to all dates of service in this appeal. 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 services have been met. Therefore, we decided that the Plan has to pay for planning services (CPT 77014) provided to the enrollee from October 18, 2019 to October 29, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided from August 30, 2019 through November 22, 2019.You asked the Plan to waive the copayment for wound debridement. You say that you thought seeing a specialist would only have a $50 copayment. You say that you were unaware of the cost associated with the services.The Plan denied your request. The Plan says the copayments 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 a $395 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges and a $90 copayment for each emergency room visit. You have been asked to pay a total of $1,531.92 for wound debridement. The wound debridement provided on August 30, 2019 and October 4, 2019 through November 22, 2019 fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The wound debridement provided on September 26, 2019 fall 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 wound debridement provided from August 30, 2019 through November 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on December 18, 2019.You asked the Plan to waive the copayment for the colonoscopy. You say that you did not find out that you had to pay $150 until after the service was provided. You say you should not have to time pay this as a one courtesy. 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 $150 copayment per visit, per provider, per day for surgery performed in an ambulatory surgical center or outpatient hospital setting. You have been asked to pay a $150 copayment for the colonoscopy. The colonoscopy 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 colonoscopy provided on December 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator provided on December 5, 2019.
You asked the Plan to waive the coinsurance for the oxygen concentrator. You say that you shouldn't have to pay for the oxygen. You say that insurance should pay for all of it. 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 copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 10% coinsurance for Medicare-covered items and related supplies. You have been asked to pay $13.50, which is 10% of the allowed amount for the oxygen concentrator. The allowed amount is $135 ($135 x 10% = $13.50). The oxygen concentrator falls within the "Durable medical equipment (DME) and related 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 coinsurance for the oxygen concentrator provided on December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction provided on January 13, 2020.You asked the Plan to pay for the refraction. You say that you went to see the doctor because you thought you had a film over your left eye.The Plan denied your request. The Plan says that this is not a covered service when not done for routine vision purposes.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 received during a routine eye exam.We looked at the file and the Plan's rules. You did not receive the refraction during a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met.Therefore, we decided that the Plan does not have to pay for the refraction provided on January 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on September 11, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 28090, 27691, 27680, and 27658 are not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 28090 is excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or ganglion); foot. The definition of code 27680 is tenolysis, flexor or extensor tendon, leg and/or ankle; single, each tendon. We find that CPT codes 28090 and 27680 are not supported in the medical record. Specifically, the operative report does not contain documentation of an excision of a foot lesion to support code 28090, documentation of a tenolysis on flexor or extensor tendon to support code 27680. 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 surgical services rendered on September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on November 19, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items orderedand for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have topay fora lumbar-sacral orthosis (L0650) provided to the enrollee on November 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oncotype DX DCIS testing.
You asked the Plan to pre-approve the Oncotype DX DCIS testing. You say that the records provided support the need for the requested service. The Plan denied your request. The Plan says medical necessity has not been met because the records show that the enrollee had a right and left mastectomy.
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 the Oncotype DX DCIS testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has already undergone bilateral mastectomies for her cancer. She is not considering breast conserving surgery and the results of the requested test will not be used to determine the need for radiation in conjunction with breast conserving surgery. 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 Oncotype DX DCIS testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Oncotype DX DCIS testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered to you on January 2, 2020. You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was 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 a $340 copayment for in-network Medicare-covered surgical and non-surgical services in an outpatient department of a hospital. Review of the file shows that you received outpatient surgical services on January 2, 2020. Per your contract with the Plan, there is a $340 copayment for in-network Medicare-covered surgical and non-surgical services in an outpatient department of a hospital. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $49.19. Given that the allowed amount was less than the $340 copayment, you have been asked to pay $49.19 for these services. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered to you on January 2, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea replacement Tandem insulin pumpYou asked the Plan to pre-approvethe replacement pump. You say that this is medically necessary.The Plan denied your request. The Plan says the current pump is less than five years old, and is still functional.The Plan must follow Medicare rules. Medicare rules say that durable medical equipment may not be replaced before the reasonable useful lifetime of five years.The file shows that your currently functional Tandem insulin pump is four years old. It cannot be replaced yet, according to Medicare guidelines. Based on this information, we decided that Medicare rules for coverage of the replacement pump have not been met.Therefore, we decided that the Plan does not have to pre-approvea replacement Tandem insulin pump
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay foran automatic external defibrillator provided on October 19, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe automatic external defibrillator. You say that the records provided support the need for the device in dispute.The Plan denied your request. The Plan says the enrollee sought non-emergent/urgent services on his own with a non-contracting provider and did not allow the primary care physician to request approval from the health plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foran automatic external defibrillator provided on October 19, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam rendered to you on December 12, 2019.You asked the Plan to waive the copayment for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the copayment was 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 a $50 copayment for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye. Review of the file shows that you received an eye exam on December 12, 2019. You have been asked to pay a $50 copayment for these services. These services fall within the Medicare-covered exam to diagnose and treat diseases or conditions of the eye 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 eye exam rendered to you on December 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe King i8 360 Smart Bed and King 360 FlexFit 3 purchased on October 8, 2019.You asked the Plan to reimburse you forthe King i8 360 Smart Bed and King 360 FlexFit 3. You say that you had a physician order and your reason for needing the bed were documented.The Plan denied your request. The Plan says only hospital beds are covered by Medicare and the Plan.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Hasa medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate needfor a change in body position.We looked at the file and Medicare rules. Only hospital beds are covered by Medicare and you did not request prior authorization for the provider. Based on this information, we decided that Medicare rules for coverage of the King i8 360 Smart Bed and King 360 FlexFit 3 have not been met.Therefore, we decided that the Plan does not have to reimburse you forthe King i8 360 Smart Bed and King 360FlexFit 3 purchased on October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on May 29, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on May 29, 2019.