Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry visit provided on September 2, 2020.

You asked the Plan to waive the copayment for the podiatry visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received podiatry services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $40 copayment for Podiatry services. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a podiatry visit on September 2, 2020. You have been asked to pay a $40 copayment for the podiatry visit. The podiatry visit falls within the Podiatry 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 copayment for the podiatry visit provided on September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse additionally for the non-Medicare covered eyewear provided on October 7, 2020.

You asked the Plan to reimburse additionally for the non-Medicare covered eyewear. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says you have been reimbursed the full amount allowed for non-Medicare covered eyewear.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services with an allowance up to $75 for non-Medicare covered eyewear. 

We looked at the file and the Plan's rules. The file shows that you have been reimbursed the full allowance towards your eyewear. Based on this information, we decided that the Plan's rules for coverage of the non-Medicare covered eyewear have not been met. Therefore, we decided that the Plan does not have to reimburse additionally for the non-Medicare covered eyewear provided on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit to your primary care provider (99497) on July 13, 2020.

You asked the Plan to waive the copayment for the visit to your doctor. You say that you get one free wellness visit per year. The Plan denied your request. The Plan says it is true that you get a wellness visit each year at no cost to you, but the services provided at your doctor's office went beyond the scope of a typical wellness visit and were not billed as an annual visit. A visit with your provider outside of a yearly check-up has a $15 copayment.

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 $15 copayment for a visit with your primary care provider. 

You have been asked to pay a $15 copayment for the visit to your doctor. The office visit provided on July 13, 2020 was billed as an advanced care planning consultation without an annual wellness visit code. The service billed only qualifies as part of an annual wellness visit when it is accompanied by a qualifying billing code. Therefore, this visit is not considered a wellness visit and is subject to a $15 copayment. 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 to your primary care provider (99497) on July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 30, 2020

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 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 physician's services provided on July 30, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the cataract removal surgery services (66984) provided on November 4, 2020.

You asked the Plan to reduce the copayment for the surgical services. You say that you should only have a $175 copayment because the services were provided in an ambulatory surgical center and not in the outpatient hospital facility. The Plan denied your request. The Plan says the $250 copayment applies because the ambulatory center is affiliated with 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 $250 copayment for outpatient surgical services. 

You have been asked to pay a $250 copayment for the surgery services. The cataract surgery falls within the outpatient surgical services benefit category. Because the facility that provided the services was associated to a larger hospital and was not a free-standing ambulatory surgical center, the facility qualifies as 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 reduce the copayment for the cataract removal surgery services (66984) provided on November 4, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit to the emergency room.

You asked the Plan to waive the copayment for the emergency room visit. You say that you did not choose to go to the emergency room; you were sent there following a sonogram you had scheduled and were only in the emergency department for 10 minutes. The Plan denied your request. The Plan says you were seen by the emergency department and emergency care has a $100 copayment.

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 $100 copayment for emergency care.

You have been asked to pay a $100 copayment for an emergency room visit. An emergency room visit falls within the emergency care 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 visit to the emergency room.

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 chiropractic treatment.

You asked the Plan to pay for the chiropractic treatment. The Plan denied your request. The Plan says that your Plan does not have any out-of-network benefits unless the services are due to an emergency, urgent care or if the provider obtains prior approval.

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 chiropractic treatment. 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 chiropractic treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitors (CGM).

You asked the Plan to pre-approve CGM. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary or reasonable.

The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve CGM. Our reviewer says that the item is not medically necessary. Our physician reviewer found the enrollee is not insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CGM have not been met. Specifically, the enrollee does not meet the criteria for a CGM as the enrollee is not insulin treated. This means the item is not medically necessary or reasonable for this enrollee. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitors (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.

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 the spacer device is experimental. More research is needed to show safety and efficacy of the device.

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 Superion device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the stationary bike purchased on June 23, 2020.

You asked the Plan to reimburse you for the stationary bike. You say that you want the Plan to reimburse you $150 for the exercise equipment. The Plan denied your request. The Plan says the purchase was made prior to the temporary benefit period of October 1, 2020 to December 31, 2020.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The Plan had a temporary Wellness Reimbursement period for fitness equipment. Your purchase was outside the benefit period. Therefore, we decided that the Plan does not have to reimburse you for the stationary bike purchased on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the optometry visit and services (99212, G0467).

You asked the Plan to reduce the copayment for the optometry services. You specifically request that the copayment be reduced to $15, which is the copayment that is required for an annual routine eye exam. The Plan denied your request. The Plan says that the services were diagnostic rather than routine and the copay was 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 $45 copayment for an outpatient visit for services to diagnose and/or treat a disease or condition of the eye.

You have been asked to pay a $37.81 copayment for optometry services. In this case, you say that this was a routine eye exam. However, you also state that you went to see a doctor because you had an inflamed eye. When you have an examination to look at and address a specific problem, this is considered diagnostic rather than a routine exam or screening. Therefore, the service provided is correctly considered an outpatient visit for services to diagnose and/or treat a disease or condition of the eye, which has a $45 copay. 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 reduce the copayment for the optometry visit and services (99212, G0467).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement of lead wires with code A4557.

You asked the Plan to pay for the lead wires. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a TENS unit has been purchased in the previous 12 months.

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 A4557 is Lead wires, (e.g., apnea monitor), per pair. We find that CPT code A4557 is not supported in the medical record. Specifically, the records show that lead wires were provided within the last 12 months. There are insufficient records to show that additional lead wires were medically reasonable and necessary for the enrollee's device. Based on this information, we decided that Medicare rules for coverage of the lead wires have not been met. Therefore, we decided that the Plan does not have to pay for the replacement of lead wires with code A4557.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation with dental code D0180.

You asked the Plan to pay for dental code D0180. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a comprehensive periodontal evaluation with dental code D0180 is not covered under the 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, dental code D0180 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation with dental code D0180.
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 19, 2020 to February 19, 2020.

You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

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, a RAP claim was not billed, and the billed claim was not a "No-RAP" LUPA. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 19, 2020 to February 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

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 a bone replacement graft.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services.

You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 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 diagnostic radiology services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital services provided from July 24, 2020, to August 5, 2020, billed on a single inpatient claim.

You asked the Plan to pay for the hospital services as billed. You say that you believe that these services should be covered. The Plan denied your request. The Plan says outpatient services that were provided more than three days before inpatient admission cannot be included on the inpatient claim.

The Plan must follow Medicare rules. Medicare rules say that outpatient services provided within three days of an inpatient admission must be included in the inpatient claim. Services provided more than three days prior to admission cannot be included on the claim. 

In this case, the enrollee was admitted to inpatient status on July 28, 2020. As such, outpatient care provided on July 24, 2020 must be billed on a separate outpatient claim. Therefore, we decided that the Plan does not have to pay for the hospital services provided from July 24, 2020, to August 5, 2020, billed on a single inpatient claim.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of comparative medical trials/studies that show the effect of bioimpedance on medical outcomes for the detection of lymphedema.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found a request for Bioimpedance spectroscopy was made for screening for lymphedema. Current available evidence does not include high quality comparative studies which clearly show benefit of bioimpedance over standard monitoring in this clinical situation. Therefore, this request for bioimpedance testing will be considered not medically necessary at this time.

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 pre-approve bioimpedance spectroscopy for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to 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. You appear to be improving and require only short-term acute care services to help complete the required treatment in a hospital setting. You do not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services. 

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 long term acute care hospital (LTACH) services.