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

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider.

You asked the Plan to waive the copayment for inpatient hospital stay and an outpatient surgery. You say that you were told one thing and then you were charged $10,000. You say that you do not understand why. 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 $325 copayment for outpatient surgery/in-network/outpatient hospital.

The enrollee has been asked to pay $145.18 which is less than the copayment amount of $325 for an outpatient surgery. Outpatient surgery falls within the outpatient surgery/in-network/outpatient hospital 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out -of-network provider.

You asked the Plan to pre-approve the physician's services to be provided by the out-of-network provider. The Plan denied your request. The Plan says services with a non-contracted provider can be approved when the service is urgent/emergent (prior authorization is not required for urgent/emergent services) or the service cannot be done within the Plan's network of contracted providers. Your records do not show that you need immediate emergency treatment. The services are available within Plan's network of contracted providers.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 the laboratory services are not supported in the medical record. Specifically, these services should be reported with code 81479 only. In addition, the appropriate DEX Z code identifier should be entered adjacent to the code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation services.

You asked the Plan to pay for the transportation services by stretcher van (T2005). You say that you needed transportation from one covered facility to another. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for stretcher van transport services. 

The services you have asked the Plan to pay for are stretcher van transport services. Therefore, we decided that the Plan does not have to pay for the transportation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the porcelain fused crown (D2751), with a prefabricated post and core (D2954) and endodontic therapy (D3310).

You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental 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 pre-approve the porcelain fused crown (D2751), with a prefabricated post and core (D2954) and endodontic therapy (D3310).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit.

You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit and you should not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $30 copayment for primary care provider visits.

The medical records show that you received services beyond an annual wellness exam on October 29, 2020. Therefore, you are responsible to pay the $30 copayment.

You have been asked to pay a $30 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 an office visit.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay separately for TOF.

You asked the Plan to pay for Train of Four testing (TOF 95999). You say that the Plan should pay this claim. The Plan denied your request. The Plan says TOF testing is considered a bundled procedure.

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 TOF is part of a bundled payment for the primary procedure. Based on this information, we decided that Medicare rules for coverage of Train of Four testing (TOF 95999) have not been met. Therefore, we decided that the Plan does not have to pay separately for TOF.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a participating provider.

You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that this was supposed to be a screening. 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 $250 copayment for outpatient surgery.

The enrollee has been asked to pay a $250 copayment for a diagnostic colonoscopy. Evidence was provided to show that polyps were 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. A diagnostic colonoscopy 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 a diagnostic colonoscopy provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy, molar tooth (D3330) and prefabricated post and core in addition to crown (D2954).

You asked the Plan to pay for the endodontic therapy and prefabricated post and core. You say that you were told before you enrolled in the Plan that your dentist was in-network. The Plan denied your request. The Plan says the prefabricated post and core is not covered by the Plan and the cost of OON services is higher than if you receive services in-network.

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.

You have been asked to pay a coinsurance of $543 ($724 allowed amount x 75% coinsurance = $543 cost share) for the endodontic therapy. Additionally, you may be billed by the OON provider for any amount greater than the payment made by the Plan to the provider. This means that you have been asked to pay the correct cost-share for the endodontic therapy based on your contract with the Plan. Therefore, we decided that the Plan does not have to waive the cost-sharing for the endodontic therapy, molar tooth (D3330).

Though the Plan offers a dental benefit in excess of Medicare coverage, the prefabricated post and core in addition to crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954).

Your complaint about potentially receiving misinformation about the network status of your dental provider when you signed up for your plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fitness equipment.

You asked the Plan to pay for fitness equipment. You say that you feel that this should be a covered benefit. The Plan denied your request. The Plan says purchases of fitness equipment does not qualify for reimbursement.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan only covers the item when purchased between October 1, 2020, through December 31, 2020.

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of fitness equipment have not been met. Specifically, the fitness equipment at issue was not purchased between October 1, 2020, through December 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory drug testing (CPT code(s): 80307 and G0481) provided to the enrollee.

You asked the Plan to pay for the laboratory drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

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 laboratory drug testing have not been met. Healthcare Common Procedure Coding System (HCPCS) code G0481 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected and received by the lab. It is noted multiple attempts were made to obtain additional information from the provider.

Current Procedural Terminology (CPT) code 80307 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected and received by the lab. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory drug testing (CPT code(s): 80307 and G0481) provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.

You asked the Plan to pre-approve a grab bar. You say that this is medically necessary. 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 grab bars are not covered because they are not primarily medical in nature. 

While a grab bar 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 grab bar.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse you the Wellness Allowance for the exercise bike purchased on April 2, 2020.

You asked the Plan to reimburse you the Wellness Allowance of $150. You say that the information you received did not say when the equipment had to be purchased. The Plan denied your request. The Plan says that the effective date for the change was October 1, 2020, to December 31, 2020.

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 has not provided documentation that you were advised of the start and end date of the reimbursement period. Therefore, we decided that the Plan has to reimburse you the Wellness Allowance for the exercise bike purchased on April 2, 2020.

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 pre-approve MOHS surgery.

You asked the Plan to pre-approve MOHS surgery. You say that this surgery is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Mohs micrographic surgery. The Maximus Physician Reviewer determined the criteria for coverage of the requested procedure are met, as MOHS surgery is covered for "BCC of greater than 0.6 centimeters on the face". The Plan argues that the Maximus physician reviewer overturned the plan's denial based on a lesion on the enrollee's forehead that was previously treated with MOHS surgery in 2019. The procedure at issue was for a shoulder lesion in 2020. Our Medical Director says the medical records show a diagnosis of Basal cell carcinoma of skin of the left shoulder. This means the Plan is correct in this case. Medicare LCD L35702 does not provide coverage for MOHS surgery for the surgical treatment of primary nodular BCC on the shoulder.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MOHS surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve MOHS surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentations.

You asked the Plan to pre-approve percutaneous vertebral augmentations. You say that you would like reconsideration because this service is recommended and medically necessary. The Plan denied your request. The Plan says this provedure is not covered for T4 level of the spinal column.

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 percutaneous vertebral augmentations. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding the age of the compression fracture(s.) Furthermore, pain is noted to be at 4/10 (below the LCD of 5+) as well as there is documentation of a T4 compression fracture. The later location is proximal to the LCD of T5. Exceptional indications or circumstances are not evident. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous vertebral augmentations have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebral augmentations.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic screening testing (CPT code 87149) provided to the enrollee on October 11, 2020.

You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says this service is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. The enrollee's diagnosis is cough. These services are not authorized because molecular genetic screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes. This is not a COVID screen test. Therefore, we decided that the Plan does not have to pay for molecular genetic screening testing (CPT code 87149) provided to the enrollee on October 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided on January 24, 2020.

You asked the Plan to pay for the anesthesia services provided during inpatient services. You say that this claim should be paid. The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services.

The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary during an inpatient stay. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. 

This was an inpatient service. Payment for this service would have been included under the global facility claim. Payment to you for this service is the responsibility of the facility or hospital. Based on this information, we decided that Medicare rules for coverage of the anesthesia services provided during inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services provided on January 24, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department services (CPT 99285) provided to the enrollee on July 17, 2020.

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 the claim was processed correctly per how the provider billed for the services.

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 99284 is "Emergency department visit for the evaluation an management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medicare decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problems(s) are of high severity, and required urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function for reimbursement consideration." 

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 reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the documentation supports a detailed history and examination, however, the documentation does not support medical decision making for CPT 99284, with one diagnostic test CPT 99283 would be a more appropriate code to report. 

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 not been met. Therefore, we decided that the Plan does not have to pay for emergency department services (CPT 99285) provided to the enrollee on July 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 17, 2020.

You asked the Plan to pay for the ambulance services. You say that your husband transported you to the hospital the ambulance service did not. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on September 17, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 17, 2020.