Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammography provided on April 9. 2021.
You asked the Plan to waive the copayment for these services. You say that you should not have a copayment for these services. The Plan denied your request. The Plan says that the claim processed 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 $200 copayment for outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $90.97 copayment for these services. These services fall within the outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic mammography provided on April 9. 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit and an EEG provided by a
participating provider on May 6, 2021.
You asked the Plan to waive the deductible for an office visit and an EEG. You say that you did not know this
provider was out-of-network. The Plan denied your request. The Plan says the correct deductible has been
applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $750 deductible which applies to what is your plan deductible.
The item or service you asked the Plan to waive the copayment for falls within the benefit category what is
your plan deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a
$750 deductible which applies to certain services. This cost sharing is a contractual obligation that had not been
met at the time an office visit and an EEG was received on May 6, 2021. The total amount you are being asked
to pay is $630.34. Therefore, we decided that the Plan does not have to waive the deductible for an office visit
and an EEG provided by a participating provider on May 6, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department services (99053, 99283) provided to
the enrollee on February 17, 2021.
You asked the Plan to pay for the services. You say that the enrollee was seen twice on the same date of service
at two different times and/or by two different providers. The Plan denied your request. The Plan says a
modifier was not billed on the claim to represent the services as separate/distinct.
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 the denied codes is:
CPT 99053:
Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service
CPT 99283:
Emergency department visit for the evaluation and management of a patient
We asked our coder 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 reviewer found when billing two evaluation and
management services for the same day, modifier 27 Multiple Outpatient Hospital E/M Encounters on the Same
Date should be appended. Therefore, billing CPT 99053 and CPT 99283 for same date of service without the
appropriate modifier would not be covered.
We looked at this coder'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 (99053, 99283) provided to the enrollee on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care (99291) provided on December 26, 2020.
You asked the Plan to pay for critical care. You say that this is supported in the records. The Plan denied your request. The Plan says this is not documented.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent on this service is not documented in the records. Based on this information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99291) provided on December 26, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from January 5, 2021 to February 17, 2021.

You asked the Plan to pay for home health 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. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was billed with an invalid type of bill. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 5, 2021 to February 17, 2021.
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 IRF care is necessary. The Plan denied your request. The Plan says admission to IRF was denied as not meeting IRF criteria, not medically necessary, and a lower level of care might be appropriate.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on August 14, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the primary payer has made full payment.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, Medicare will not make a secondary payment if the provider/physician/supplier accepts, or is obligated to accept, the primary plan payment as full payment or full satisfaction of the patient's responsibility. We looked at the file and Medicare rules. In this case, the primary payer has made payment for the services in question that satisfies the enrollee's responsibility. This means that the secondary payer, the Plan, is not responsible for making further payment on this claim. Therefore, we decided that the Plan does not have to pay for the services provided on August 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for the enrollee.
You asked the Plan to pre-approve a power seat elevation feature. You say that this is medically necessary. The Plan denied your request. The Plan says that this item is non-covered.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 20, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claims were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on July 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care following elective surgery is not medically necessary. The Plan denied your request. The Plan says the criteria for inpatient hospital care following elective surgery
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is a 66-year-old female with a past medical history of hypertension, hyperlipidemia, and chronic kidney disease who is presenting with persistent left hip pain affecting function despite conservative measures. She is medically stable and has been provided medical clearance to undergo this elective procedure. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with a gastroenterologist
on June 11, 2021.
You asked the Plan to waive the copayment for the gastroenterology visit. You say that this was a hospital
observation, not an office visit, so no copayment should apply. 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 services with a specialist.
You have been asked to pay a $30 copayment for the gastroenterology visit. Your Evidence of Coverage says
that this copayment also applies to services rendered in an outpatient hospital facility. 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 a gastroenterologist on June 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0429, A0425) provided on January 29, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you were dissatisfied with the services provided and feel you should not have to pay this bill. You say you have an active case against this provider. The Plan denied your request. The Plan says this claim was processed appropriately, and the correct copayment was 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). Your contract with the Plan clearly says that you must pay a $250 copayment for each one-way Medicare-covered ground ambulance trip. You have been asked to pay a $250 copayment for the ambulance services. 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. We have read your letter and it sounds as though you may have a quality of care concern, but no statement or description of the problem was provided. Maximus Federal Services cannot address quality of care issues. Therefore, we decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0429, A0425) provided on January 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for diagnostic services and a biopsy provided from December 14, 2020, to December 18, 2020.
You asked the Plan to waive the coinsurance for diagnostic services and outpatient surgery. You say that you have been a patient with this provider since 1998 and were never advised that they were out-of-network. The Plan denied your request. The Plan says the coinsurance 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 50% coinsurance for out-of-network diagnostic services and outpatient surgery. The allowed amounts of these claims total $686.08, resulting in a total coinsurance responsibility of $343.06. You have been asked to pay 50% coinsurance for diagnostic services and outpatient surgery. Diagnostic services and outpatient surgery fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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 diagnostic services and a biopsy provided from December 14, 2020, to December 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you are in severe pain. The Plan denied your
request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychotherapy visit (90837) provided on May 5, 2021.
You asked the Plan to pay for a psychotherapy visit. You say that all your other claims for therapy have been
approved and you do not understand why you cannot get coverage to see an out-of-network provider when you
have in the past. The Plan denied your request. The Plan says 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 records show that all other psychotherapy visits in the past were rendered by an in-network provider. The
services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has
opted out of the Medicare program. The records provided for review do not show that the services at issue were
urgent or emergent. Therefore, we decided that the Plan does not have to pay for a psychotherapy visit (90837)
provided on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the enrollee has chronic pain that interferes with
regular daily activities. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 64447 provided on March 30, 2021.
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 64447 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded 64447 provided on March 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 84484, 80048, 85025, and 85610 provided on January 24, 2021.

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 CPT codes 84484, 80048, 85025, and 85610 are not supported in the medical record. Specifically, the codes billed for these services were billed with modifier 26. These codes have a professional component/technical component is "9" which indicates that modifier 26 does not apply to these codes. 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 coded 84484, 80048, 85025, and 85610 provided on January 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic testing you received on April 16, 2021.
You asked the Plan to waive the copayment. You say that you should only have a $45 copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $50 copayment for Medicare-covered outpatient diagnostic tests. Review of the file shows that you were provided diagnostic services on April 16, 2021. Per your contract with the Plan, there is a $50 copayment for outpatient diagnostic tests. This cost sharing is a contractual obligation that you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was$42.98. Given that the allowed amount was less than the $50 copayment, you have been asked to pay $42.98 for these services. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic testing you received on April 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on October 14, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until April 6, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided on October 14, 2019.