Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from March 20, 2021, to March 25, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were never advised that a copayment would apply. You also stated that you were not satisfied with the care you received. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that this is a per-day charge regardless of the services you receive while you are in the hospital.
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 $295 copayment per day for days 1-7 for inpatient hospital services. Records show you were in the hospital for five days. You have been asked to pay a $295 copayment per day
for the inpatient hospital services, for a total of $1475. This copayment applies regardless of the extent of services you receive in the hospital. 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 inpatient hospital services you received from March 20, 2021, to March 25, 2021.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99326) rendered by the out-of-network (OON) provider on March 1, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99326) rendered by the out-of-network (OON) provider on March 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs you received on April 20, 2021.
You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you have cancer and are undergoing treatment. You do not believe you should have to pay this coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the chemotherapy drugs. The chemotherapy drugs fall within the Medicare Part B drugs 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 chemotherapy drugs you received on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray exam of the knee (73560), an x-ray exam of the
ankle (73610) and an x-ray exam of the foot (73630) provided on January 15, 2021, by an out-of-network
(OON) provider.
You asked the Plan to pay for radiology services. You say that the member had several exams on this date of
service. You also say you would like the claims reconsidered for processing. The Plan denied your request. The
Plan says there are in-network providers available for these services.
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. The records provided for review do not show that the services at issue were urgent or
emergent. 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 an x-ray exam of the knee (73560), an x-ray exam of the ankle
(73610) and an x-ray exam of the foot (73630) provided on January 15, 2021, by an out-of-network (OON)
provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer device.

You asked the Plan to pre-approve the Superion procedure. You say that this is a proven treatment that will be helpful. The Plan denied your request. The Plan says there is not sufficient evidence to support this service at this time.

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 Superion procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Superion spacer remains experimental at this time. More research is needed to support medical necessity. 

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 Superion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the SNF services are medically necessary. The Plan denied your request. The Plan says 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee's 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00770) provided by a second physician on February 26, 2021.
You asked the Plan to pay for anesthesia services. You say that two anesthesiologists were required. The Plan denied your request. The Plan says a second provider is not supported.
The Plan must follow Medicare rules. Medicare rules say that if anesthesiologists are in a group practice, each physician member may furnish different component parts of the anesthesia service. However, the medical record must indicate that the services were furnished by physicians and identify the physicians who furnished them.
We looked at the file and Medicare rules. While the medical records list two anesthesia practitioners, the documented services are only attributed to the first physician, whose services were previously billed and paid. Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (00770) provided by a second physician on February 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81226, 81230, 81231,
81232, 81240, 81241, 81247, 81283, 81328, 81335, 81350, 81381, 81406, and 81407) provided to the enrollee
on November 11, 2020.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. The enrollee had molecular
pharmacogenetic testing. The denial remains upheld as non-covered as Medicare denies coverage when a
laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of
the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the
panel. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s):
81226, 81230, 81231, 81232, 81240, 81241, 81247, 81283, 81328, 81335, 81350, 81381, 81406, and 81407)
provided to the enrollee on November 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed
tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image
postprocessing under concurrent supervision; not requiring image postprocessing on an independent
workstation (CPT code 76376) provided to the enrollee on February 20, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says the use of 3D-rendering with interpretation and reporting of computed tomography, magnetic
resonance imaging, or other tomographic modality with image postprocessing is not covered separately by
Medicare as it is contained in the authorized radiologic procedure. The Plan states radiologic techniques using
3D-rendering will be considered integral to the radiology services and not a separate service. The Plan states
reimbursement will be based on the payment for the primary radiologic imaging service.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the service have not been met. Radiologic techniques using 3Drendering
will be considered integral to the radiology services and not a separate service. The Plan states
reimbursement will be based on the payment for the primary radiologic imaging service. Therefore, we decided
that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed tomography,
magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under
concurrent supervision; not requiring image postprocessing on an independent workstation (CPT code 76376)
provided to the enrollee on February 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit for assessment and management of a patient (G0463) and the hemorrhoidectomy, internal, by rubber band ligation (46221) rendered by the out-of-network (OON) provider on November 9, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior 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 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 hospital outpatient clinic visit for assessment and management of a patient (G0463) and the hemorrhoidectomy, internal, by rubber band ligation (46221) rendered by the out-of-network (OON) provider on November 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on March 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that it is the nursing facility's responsibility to obtained prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
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 skilled nursing
services provided on March 9, 2021 by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (36415, 83036, 84443) rendered by the out-of-network (OON) provider on March 12, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior 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 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 laboratory services (36415, 83036, 84443) rendered by the out-of-network (OON) provider on March 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.

You asked the Plan to pre-approve a stair glide. You say that you cannot get to your shower safely without the stair glide. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. 

While a stair lift may 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-approve a stair glide.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the sleep study you had on April 26, 2021.
You asked the Plan to waive the coinsurance for the sleep study. You say that since the machine they sent you home with did not produce usable results, you should not have to pay this coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for sleep studies. You have been asked to pay 20% coinsurance for the sleep study. This coinsurance applies regardless of your satisfaction with the results of the test. 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 sleep study you had on April 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
You asked the Plan to pre-approve Euflexxa. You say that the enrollee needs this for the enrollee's osteoarthritis. The Plan denied your request. The Plan says that the notes do not state if there was any improvement with previous treatment provided on April 23, 2021.
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation is considered not medically reasonable and necessary and will not be covered when a repeat series of injections is initiated prior to six months after completion of the previous course of treatment. We looked at the file and Medicare rules. The file indicates the enrollee received viscosupplementation less than six months ago. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this si medically necessary. The Plan denied your request. The Plan says there is no recent record of surgical consultation for determination of appropriateness of surgical management.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for a swallowing function test. We decided that the Plan does not have to waive the copayment for an X-ray.

You asked the Plan to waive the copayments for an X-ray and a swallowing function test. You say that the tests were due to your previous diagnosis of the coronavirus and you thought you would not owe any charges related to it. The Plan says that the claims were processed correctly and you are being charged the correct amount.

We decided that the Plan has to reduce the copayment for a swallowing function test provided on March 24, 2021, from $30 to $10.

The Plan says that you must pay a $30 copayment for a swallowing function test. However, a swallowing function test is considered a diagnostic procedure and test and you cannot be asked to pay more than a $10 copayment. Therefore, we decided that the Plan has to reduce the copayment for a swallowing function test from $30 to $10.

We also decided that the Plan does not have to waive the copayment for an X-ray provided on March 24, 2021.

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 $35 copayment for an X-ray. Therefore, we decided that the Plan does not have to waive the copayment for an X-ray.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with an orthopedic specialist on December 22, 2020.
You asked the Plan to waive the copayment for the orthopedic visit. You say that you were told that because you had had other consultations where similar services were received, that you did not have to pay a copayment for this visit. The Plan denied your request. The Plan says you were charged this copayment 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 $30 copayment for visits with a specialist. You have been asked to pay a $30 copayment for the orthopedic visit. The orthopedic visit falls within the visits with a specialist benefit category. There is no provision in your contract for a waiver of this copayment
for any reason. 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 visit you had with an orthopedic specialist on December 22, 2020.