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

We decided that the Plan does not have to pre-approvea bath transfer bench.You asked the Plan to pre-approvea bath transfer bench. You say that you arenot able to get into the bathtub for a shower.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that bath transfer benches are not covered because they are not primarily medical in nature. While a bath transfer benchmay be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea bath transfer bench
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lenses purchased on December 11, 2019.
You asked the Plan to pay for the lenses. You say that you cannot understand why the plan would not you to go
with the lesat expensive alternative. The Plan denied your request. The Plan says that you must use a doctor in
our vision network.
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 obtained from a doctor in your vision network.
We looked at the file and the Plan's rules. The file indicates you did not receive these services from a network
provider. Based on this information, we decided that the Plan's rules for coverage of the lenses have not been
met. Therefore, we decided that the Plan does not have to pay for the lenses purchased on December 11, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the video EEG interpretation. We decided that the Plan does not have to pay for the EEG interpretation provided on September 28, 2019.
You asked the Plan to pay for the video EEG interpretation. You say that the documentation supports all of the billed services and there is no issue which justifies the denial of this claim. The Plan says that there is no date reported for when the EEG was performed and the video EEG showed that the enrollee was connected for 54 hours which does not support three units of 95861. We decided that the Plan has to pay for the video EEG interpretation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The CPT code definition of 95861 is Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation (eg, for presurgical localization), each 24 hours.
This code is paid per 24-hour period. As the documentation supports that more than 48 hours of this recording was performed, the amount of time above 48 hours is reimbursed in the third unit of this code. We find that three units of this code are supported. Therefore, we decided that the Plan has to pay for the video EEG interpretation.
We also decided that the Plan does not have to pay for the EEG interpretation provided on September 28, 2019.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The documentation does not clearly indicate that an EEG was performed on September 28, 2019. There is no full copy of the report in the documents submitted, and the document which do mention this service do not support the date of service billed on the claim. Therefore, we decided that the Plan does not have to pay for the EEG interpretation provided on September 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services provided on September
5, 2019.
You asked the Plan to waive the copayment for physician services. You say that you were not informed the
phone conversation would be classified as a patient visit. You say that the billing of the visit is unfounded. The
Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5
copayment for web/phone based technology up to unlimited per year
You have been asked to pay a $5 copayment for physician services. The physician services fall within the
"Web/Phone Based Technologies" 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
physician services provided on September 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the knee
(73721).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied
your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.
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 MRI. Our reviewer says that rules
for coverage have not been met. Our physician reviewer found there is no documentation of a complaint of
knee pain, no review of systems related to knee issues, no examination of the knee and no reasonable
differential diagnosis related to knee issues. It is entirely unclear why an initial knee x-ray was ordered and,
given that the x-ray was without findings, why a subsequent MRI was ordered.
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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve Magnetic Resonance Imaging (MRI) of the knee (73721).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on October 11, 2019  through October 13, 2019. You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration
because these services were billed correctly. The Plan denied your request. The Plan says the claim was not
submitted with the required modifier to process and pay.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that the physical therapy services are not supported in the record. Specifically, CPT code 97605 was
not submitted with the required GP modifier to process the claim. Based on this information, we decided that
Medicare rules for coverage of the physical therapy services have not been met. Therefore, we decided that the
Plan does not have to pay for physical therapy services provided on October 11, 2019 through October 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-covered item or service, special powered
mattress (A9270).
You asked the Plan to pre-approve the special powered mattress. You say that you have degenerative back
disease and is trying to avoid surgery. If you had this mattress you would be able to sleep and walk better. The
Plan denied your request. The Plan says complete medical records has not been received to show that the
enrollee has a covered condition that requires the need of a hospital bed or a special power mattress.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. Medicare only covers certain types of powered mattresses using specific medical
codes. Your provider must send us the correct code. Your provider must tell the plan exactly what kind of
mattress this is and why it is needed. The plan has not received complete medical records from the provider.
Based on this information, we decided that Medicare rules for coverage of special powered mattress have not
been met. Therefore, we decided that the Plan does not have to pre-approve the non-covered item or service,
special powered mattress (A9270).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transrectal ultrasound provided on December 4, 2019.
You asked the Plan to waive the copayment for the transrectal ultrasound. You say that You say you should not be responsible for the copayment because any radiology that was needed was used for the biopsy. 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 $325 copayment per day for Medicare-covered diagnostic radiology services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $325 copayment for the ultrasound.
You have been asked to pay a $150.06 copayment for the transrectal ultrasound. The transrectal ultrasound falls within the "Outpatient diagnostic services and therapeutic services and supplies" benefit category. The medical record shows a diagnosis of an elevated PSA which makes the transrectal ultrasound diagnostic in nature.
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 transrectal ultrasound provided on December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 1 power operated vehicle.
You asked the Plan to provide a Group 1 power operated vehicle (POV). You say that the enrollee needs a power wheelchair but wants a scooter. The Plan denied your request. The Plan says you does not think a scooter meets the enrollee's mobility needs due to lack of postural stability.
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. The file shows that the enrollee cannot safely operate the POV being requested. The record shows the enrollee trialed a power wheelchair not a scooter. The home assessment showed the enrollee's MRADLs would be prohibited by the tiller of a scooter. This means that Medicare rules for coverage of a POV have not been met. Therefore, we decided that the Plan does not have to provide a Group 1 power operated vehicle.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for gastric bypass sleeve surgery to be
provided by an out of network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services can be provided by 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral for gastric bypass sleeve surgery to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveendovenous ablation therapy.You asked the Plan to pre-approvethe endovenous ablation therapy. You say that you would like reconsideration because this service is medically necessary for the treatment of the member's condition.The Plan denied your request. The Plan says medical necessity criteria for this service has not been met.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 endovenous ablation therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not satisfactorily demonstrate that the member's current symptoms are either lifestyle limiting or are related to superficial venous reflux. Additionally, the member has a history of chronic deep venous obstruction.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 endovenous ablation therapy have not been met.Therefore, we decided that the Plan does not have to pre-approveendovenous ablation therapy.
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 above.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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. Your care needs can be met 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for surgical debridement procedures provided from September 3, 2019 to October 16, 2019.
You asked the Plan to waive the copayments for outpatient surgeries. You say that you were never told that you would have a copayment each time you went for treatment, or you would have found another provider. The Plan denied your request. The Plan says the copayment 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 $200 copayment per visit for in-network outpatient surgery provided by an outpatient hospital facility. There were 8 visits, resulting in a total copayment obligation of $1,600. You have been asked to pay $200 copayment for each outpatient surgery. Outpatient surgeries fall within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 for surgical debridement procedures provided from September 3, 2019 to October 16, 2019.
Your complaint regarding not being told about the cost-share for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye examination and refraction provided by provider on November 21, 2019.You asked the Plan to pay for eye exam and refraction. You say that you have been paying for vision coverage and do not understand why this was not covered.The Plan denied your request. The Plan says the copayment amount you are being charged is correct, and the denial of payment for the refraction service is correct because this visit was not routine in nature.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 $45 copayment for each in-network eye exam. Medicare rules also say that Medicare does not cover routine vision services and eyewear. The Plan has a supplemental vision care benefit which may cover refraction, however the refraction in this case is not covered by the Plan's supplemental benefits because this exam was not routine.You have been asked to pay $45 copayment for eye exam. The Plan's denial of payment for eye refraction is also correct, because refraction is not covered by the Plan as part of a non-routine eye examination.Therefore, we decided that the Plan does not have to pay for an eye examination and refraction provided by provider on November 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe air fluidized bed provided on March 23, 2018.You asked the Plan to pay forthe air fluidized bed. You say that the Plan should pay this claim.The Plan denied your request. The Plan says Medicare rules indicate that the facility should cover the air fluidized bed.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. Records show that the air fluidized bed was used in a SNF.Therefore, we decided that the Plan does not have to pay forthe air fluidized bed provided on March 23, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Zoster (shingles) vaccine (90736) provided on December 29, 2017.
You asked the Plan to pay for shingles vaccine. You say that this should be covered. The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of the enrollee's Part D prescription drug plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to shingles vaccine. Therefore, we decided that the Plan does not have to pay for a Zoster (shingles) vaccine (90736) provided on December 29, 2017.
Benefits for shingles vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99215) provided on December 4, 2019.You asked the Plan to pay forthe officevisit. You say that you would like reconsideration because similar claims have been paid for in the past.The Plan denied your request. The Plan says these services are non-covered because the provider has opted out of Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation This provider has opted out of the Medicare program. The file shows entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay foran office visit (99215) provided on December 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.
You asked the Plan to pre-approve proton beam therapy. 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. 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 proton beam therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that there is a therapeutic advantage to proton beam therapy for the enrollee. Therefore the requested treatment is not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetertiary level care with an orthopedic surgeon.You asked the Plan to pre-approvethe tertiary level of care. You say that your pain management provider recommended this provider because of your condition.The Plan denied your request. The Plan says tertiary level care is not medically necessary.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 tertiary level of care. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this surgery is routain and may be treated by any orthopedic surgeon.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 tertiary level of care have not been met.Therefore, we decided that the Plan does not have to pre-approvetertiary level care with an orthopedic surgeon.