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

We decided that the Plan does not have to pay in full for physician services (96361, 96375, 96413, J9176) provided September 24, 2020.
You asked the Plan to pay in full for the physician services. You say that the maximum out-of-pocket was reached and the services should be covered. The Plan denied your request. The Plan says you had not reached the maximum out-of-pocket at the time services were provided and the correct cost-sharing 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 the maximum out-of-pocket limit is $3,400. At the time the services at issue were provided, your amount paid out of pocket was $2,618.41. The limit was not yet reached. 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 pay in full for physician services (96361, 96375, 96413, J9176) provided September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the natalizumab injection (J2323) provided on 9/26/20.
You asked the Plan to waive the coinsurance for the injection. You say that this is too much money for the service, and nobody told you it would cost this much. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the natalizumab injection. The service at issue falls within the Medicare Part B prescription 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 the natalizumab injection (J2323) provided on 9/26/20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the full amount for the dentures provided on February 25, 2020.

You asked the Plan to reimburse the full amount for the dental item. You say that your denture was broken. You say that you could not eat or talk. You say that you had no choice but to get a new denture. You say that you paid $2,800 for the dentures that you received. You say that you were told that PPO dental will cover the whole denture expenses. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that you may pay more for dental services that you receive out of network. The Plan also says out of network providers can bill you for all differences between the amount you are reimbursed, and the amount billed by out of network dentists plus the applicable coinsurance.

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, out of network providers can bill you for the difference between the amount that they charge and the amount that the plan pays. The record shows that the Plan has reimbursed up to the allowed amount for the dentures. Therefore, we decided that the Plan does not have to reimburse more for the dentures provided on February 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the knee injections provided on July 7, 2020, and July 22, 2020.
You asked the Plan to waive the copays for the services provided. You say that the services were done in the exam room. The Plan denied your request. The Plan says the cost shares were 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 $435 copay for outpatient surgery. The file shows that you received cortisone injections on each date of service at issue. The injections are considered surgery services. You have been asked to pay a $431.09 for each date of service. Because the amount is less than the $435 copay, you have been charged the lesser amount. The services fall within the outpatient surgery 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 copays for the knee injections provided on July 7, 2020, and July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Evenity (Romosozumab) injections (96372, J3111) received June 24, 2020 and July 22, 2020.

You asked the Plan to waive the coinsurance for the Evenity injections. You say that you cannot afford the coinsurance. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare covered Part B drug. 

You have been asked to pay a 20% coinsurance for the Evenity injections. Evenity injections fall within the Medicare Part B Prescription 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 the Evenity (Romosozumab) injections (96372, J3111) received June 24, 2020 and July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive counseling services.

You asked the Plan to pay for the services provided. You say that it should be included as part of your doctor's visit. The Plan denied your request. The Plan says the service is a non-covered benefit.

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 99401 is preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual. We find that CPT code 99401 is not covered by Medicare or your plan. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the preventive counseling services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit (99213).

You asked the Plan to waive the copayment for the specialist office visit. You say that you were charged an incorrect copayment. The Plan denied your request. The Plan says the copayment 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 $50 copayment for each Medicare covered visit with a specialist.

You have been asked to pay a $50 copayment for the in-network specialist office visit. Specialist office visits fall 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 the specialist office visit (99213).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health and home physical therapy, or home with outpatient therapy.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 

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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on February 12, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network
services are not covered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an electrocardiogram, routine ECG with at least 12 leads; with interpretation and report (93000).

You asked the Plan to waive the copayment for an electrocardiogram. You say that you have had this service done once or twice a year and have always been charged $10. The Plan denied your request. The Plan says outpatient diagnostic testing falls under all other services covered at a $50 copay. The claim was paid under that benefit. You are being asked to pay $17.51 because that is the left over balance and is less than your $50 copay.

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 outpatient diagnostic tests.

You have been asked to pay a $50 copayment for an electrocardiogram. An electrocardiogram falls within the outpatient diagnostic tests 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 electrocardiogram, routine ECG with at least 12 leads; with interpretation and report (93000).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less (11042) provided from September 1, 2020, through September 22, 2020.
You asked the Plan to waive the copayment for wound debridement. You say that the services at issue aren't outpatient surgery and should be charged as a follow-up visit. The Plan denied your request. The Plan says the services at issue do reflect outpatient surgery and medical records support that you received this service on the dates of service.
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 $225 copayment for each Medicare-covered outpatient hospital facility visit for outpatient hospital services. You have been asked to pay a $225 copayment for wound debridement. The services at issue fall within the outpatient hospital 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 debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less (11042) provided from September 1, 2020, through September 22, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular laboratory services provided on May 28,
2020.
You asked the Plan to pay for the cardiovascular laboratory services. You say that you would like
reconsideration because this service was medically necessary. The Plan denied your request. The Plan says this
service was not billed correctly.
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 cardiovascular laboratory services, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Additionally, there is no clinical
documentation showing the reason the test was ordered and how it will affect treatment. Therefore, we decided
that the Plan does not have to pay for the cardiovascular laboratory services provided on May 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient residential treatment for alcohol and /or drug rehabilitation provided on July 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for inpatient residential treatment for alcohol and /or drug rehabilitation.. You say that you did not have time to receive prior authorization. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the inpatient residential treatment for alcohol and /or drug rehabilitation provided on July 30, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ostegenesis stimulator for the enrollee.
You asked the Plan to pre-approve the stimulator. You say that the enrollee is six plus weeks out from injury with little evidence of bony healing. The Plan denied your request. The Plan says the documentation shows significant improvement and healing.
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 stimulator. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee notes pain with movement of the upper arm. Exam reveals left upper extremity mild to moderate soft tissue swelling extending down into her wrist and hand, with good motor and sensory function into the wrist and all digits. There is no gross movement at her fracture site nor any significant point tenderness to palpation. X-rays dated 1/17/21 show abundant periosteal new bone formation with a persistently visible fracture line. However, bridging bone appears to be forming in abundance. There is no documentation of serial x-rays over a three month period evidencing no progressive healing to support the diagnosis of non-union at this time. There is no evidence in the available medical records that this enrollee would be considered at high risk for delayed fracture healing. Continuation of appropriate conservative fracture management was indicated at the time of this request. Therefore, the osteogenesis stimulator, low intensity ultrasound, non-invasive is not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an ostegenesis stimulator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740).
You asked the Plan to pre-approve the crown. You say that the enrollee needs a crown for tooth # 5. The Plan denied your request. The Plan says crowns are not a covered service.
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 crown (D2740).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pay for nursing facility care (99309) provided on June 10, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that this claim denied because the provider was not eligible for payment of this service. The Plan states that the NPI Registry website shows this provider is registered with a taxonomy for a nurse practitioner. However, the provider did not bill with this taxonomy. The provider billed this claim with a Registered Nurse taxonomy. Therefore, the claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate provider codes. In this case, the taxonomy code reported does not match the taxonomy code registered on the database for this provider. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for nursing facility care (99309) provided on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on October 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on October 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided from August 20, 2020, through August 28, 2020.

You asked the Plan to pay for foot orthotics. You say that you have nephropathy. 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 pay for foot orthotics provided from August 20, 2020, through August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the facet joint injections (64492) provided on September 15, 2020.
You asked the Plan to pay for the facet joint injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT 64492 has an MUE value of "1", and the provider billed "2" units.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 64492 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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pay for the facet joint injections (64492) provided on September 15, 2020.