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

We decided that the Plan does not have to waive the co-payment for the scanning computerized ophthalmic
diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (92134)
provided August 10, 2020.

You asked the Plan to waive the co-payment for the diagnostic imaging of the retina. You say that the cost of
this service should be part of the co-payment for the medical eye exam. 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 $65
co-payment for each covered diagnostic procedure or test at a network doctor's office.

You have been asked to pay $39.45 for the diagnostic imaging of the retina. This service falls within the
Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have
been asked to pay less than or equal to the co-payment 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 scanning computerized ophthalmic diagnostic imaging,
posterior segment, with interpretation and report, unilateral or bilateral; retina (92134) provided August 10,
2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on December 18, 2020.You asked the Plan to waive the copayment for an outpatient surgery. You say that the member was recommended to have a yearly colorectal cancer screening and he should not have to pay a $200.00 copay.The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment for outpatient surgery. The enrollee has been asked to pay a $200 copayment for an outpatient surgery. Evidence was provided that showed a polyp was removed. The rules say that, if during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed.An outpatient surgery falls within the outpatient surgery benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on December 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carbidopa/Levodopa for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee needs to continue on this medication for treatment of his symptoms. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Carbidopa/Levodopa for the enrollee.
Benefits for this drug 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the endoscopy procedures and related services provided by an out-of-network provider on September 9, 2020.
You asked the Plan to pay for the endoscopy procedures and related services. You say that the patient was registered with traditional Medicare, so no authorization was done. The Plan denied your request. The Plan says prior authorization was required but not obtained.
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 endoscopy procedures and related services provided by an out-of-network provider on September 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an immediate lower denture (D5140) provided on February 15, 2021.
You asked the Plan to pay for an immediate lower denture. You say that the service should be covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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 an immediate lower denture (D5140) provided on February 15, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER services provided from February 1,
2021, through February 3, 2021.
You asked the Plan to waive the copayment for the ER services. 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 $50
copayment for emergency care worldwide. You do not have to pay the copayments if you are admitted to the
hospital for inpatient care immediately after your emergency room visit. If you are not admitted as an inpatient,
or if you remain as an outpatient including an observation status, you will have to pay the copayments.
You have been asked to pay a $50 copayment for the ER visit. The ER visit falls within the "Emergency care"
benefit category. The records show you were admitted to outpatient observation. 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 ER services provided from February 1, 2021, through February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth visit (99213) provided on January 25, 2021.
You asked the Plan to pay for a telehealth visit. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with the correct POS.
The Plan must follow Medicare rules. Medicare rules say that providers should submit telehealth services claims using Place of Service (POS) 02-Telehealth to indicate they furnished the billed service as a professional telehealth service from a distant site. We looked at the file and Medicare rules. The telehealth service at issue was not billed with POS 02. Based on this information, we decided that Medicare rules for coverage of a telehealth visit have not been met. Therefore, we decided that the Plan does not have to pay for a telehealth visit (99213) provided on January 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral surgery for the enrollee.
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 these services are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve oral surgery for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on September 15, 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 September 15, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328, S9363 and 99601) provided on September 28, 2020.

You asked the Plan to pay for home infusion therapy. You say that this should be covered. The Plan denied your request. The Plan says this was not billed with valid codes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT codes S9328, S9363 and 99601 are not supported in the medical record. Specifically, these
codes have a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328, S9363 and 99601) provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 24, 2020 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says these services were rendered by an OON provider without an authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 for the subsequent nursing facility care provided on September 24, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the ambulance transportation (A0425, A0429) received August 24, 2020.

You asked the Plan to waive the co-payment for the ambulance transportation. You say that you were determined unable to drive and your provider requested ambulance services to transport you. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 $250 co-payment for Ambulance Services.

You have been asked to pay a $250 co-payment for the ambulance transportation. 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 co-payment for the ambulance transportation (A0425, A0429) received August 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for laboratory testing provided on October 9, 2020.

You asked the Plan to waive the coinsurance for lab test. You say that you were never informed how much this test would cost you, and you are on a fixed income.The Plan denied your request. The Plan says the coinsurance amount you are being charged is 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 20% coinsurance for lab services. The allowed amount of this claim is $3,873, resulting in a coinsurance amount of $774.60.

You have been asked to pay 20% coinsurance for lab test. Lab test 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 coinsurance for laboratory testing provided on October 9, 2020.

Your complaint regarding not being told about the cost-share for this service 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the member is receiving the appropriate inpatient acute care and does not require transfer to a LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 74-year-old male with a history of bronchiectasis, Chronic obstructive pulmonary disease (COPD), on home oxygen, hypertension, coronary artery disease, prostate cancer and obstructive sleep apnea on BiPAP who was admitted on May 8, 2021 for acute on chronic respiratory failure initiated on high flow nasal canula (HFNC) oxygen therapy. The enrollee was found to have a pulmonary embolism and new right upper lobe pneumonia. The progress notes on June 22, 2021 show that the enrollee remained on HFNC, respiratory rates of (30, 29, 28) and tachypneic on examination. The documentation indicates that the enrollee remains hypoxic and short of breath despite maximal therapy.
There is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upright walker.

You asked the Plan to pre-approve an upright walker. You say that you need the requested item to help with
your back pain. The Plan denied your request. The Plan says rules for an upright walker have 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 an upright walker. Our reviewer says
that the requested item is not considered medically reasonable and necessary in this case. Our physician
reviewer found that, in this case, you have a wheelchair and a walker that have been authorized. The
documentation doesn't support that the requested specialized (upright) walker is medically 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 an upright walker have not been met. Therefore, we decided that the Plan does
not have to pre-approve an upright walker.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse a greater amount for the prosthetic eye (V2623) purchased on October 27, 2020.
You asked the Plan to reimburse a greater amount for the prosthetic. You say that you were told if you paid for the service up front, you would be reimbursed for everything but the 20% coinsurance. You paid $3,800, but the Plan only reimbursed you $716.66. You are requesting a larger reimbursement. The Plan denied your request. The Plan says that the allowed amount for this prosthetic is $895.82, which means that your 20% coinsurance comes to $179.16. ($895.82 - $179.16 = $716.66). You were reimbursed the correct amount for this item.
Medicare rules say that the MAO must pay the non-contracting non-participating (non-par) DME supplier the difference between the enrollee's cost-sharing and the DME supplier's bill.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the prosthetic eye have been met. Specifically, it is the responsibility of the Plan to pay the difference between the enrollee's coinsurance and the DME supplier's bill. In this case, the Plan has only paid based on Medicare's allowed amount. This is not the appropriate amount and the Plan is responsible for additional reimbursement. Therefore, we decided that the Plan has to reimburse a greater amount for the prosthetic eye (V2623) purchased on October 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions (D7140 x 6), the complete upper denture (D5110), and the complete lower denture (D5120) provided from November 12, 2020, to February 5, 2021.

You asked the Plan to pay for the dental services. You say that you thought this plan would cover your dental. You say that you have been having problems with your teeth. You also say that you received a letter of approval for dentures.The Plan denied your request. The Plan says you have preventive dental coverage only. The Plan says that dentures are not a preventive dental service. The Plan says that extractions are not preventive dental services either.

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 extractions (D7140 x 6), the complete upper denture (D5110), and the complete lower denture (D5120) provided from November 12, 2020, to February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided from February 5, 2021, to February 16, 2021.

You asked the Plan to pay for acupuncture services. You say that you were told acupuncture was a covered benefit. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these acupuncture services were not provided for chronic low back pain.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, these services were not provided for the treatment of chronic lower back pain. Therefore, we decided that the Plan does not have to pay for acupuncture services provided from February 5, 2021, to February 16, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve Intradialytic Parenteral Nutrition.
You asked the Plan to pre-approve the Intradialytic Parenteral Nutrition. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says that the member does not meet the Plan's criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 Intradialytic Parenteral Nutrition. Our reviewer says that the Intradialytic Parenteral Nutrition is both medically indicated and appropriate. Our physician reviewer found the member is indicated for malnutrition and has had weight loss, low albumin, and failed oral supplements. The member has failed conservative treatments. 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 Intradialytic Parenteral Nutrition have been met. Therefore, we decided that the Plan has to pre-approve Intradialytic Parenteral Nutrition.