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

We decided that the Plan does not have to pay for surgical pathology services provided on December 17, 2019.
You asked the Plan to pay for the surgical pathology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 surgical pathology services provided on December 17, 2019.
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 transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer to an LTACH are not met.
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. Our physician reviewer found based on the documentation provided, you are currently undergoing treatment at an acute care hospital following surgery for complications related to Crohn's disease. You are not intubated or ventilated. There is no evidence that the care you require is not available at the current facility. As LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring you to the LTACH. 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.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for chemotherapy treatment (96413, J9299) provided on February 27, 2019.
You asked the Plan to pay for chemotherapy treatment. You say that you billed the plan but the enrollee's policy had terminated. The Plan denied your request. The Plan says that an Explanation of Benefits is required to process this claim.
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. Though the Plan states that an Explanation of Benefits is needed for this claim to be processed, they do not specify what other insurance plan the claim must be submitted to. The record does not show that the enrollee had a different primary insurance that was active at the time these services were rendered. Therefore, we decided that the Plan has to pay for chemotherapy treatment (96413, J9299) provided on February 27, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care provided on November 28, 2019.
You asked the Plan to pay for the initial hospital care. You say that the treatment provided was for services
unrelated to the enrollee's care. The Plan denied your request. The Plan says Original Medicare would be
responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal
condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on November 28, 2019. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital
care provided on November 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing services provided to the enrollee on September 27, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the submitted documentation does not itemize what tests are included in this panel; therefore the billed code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.In this case, the definition of HCPCS code G0482 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed."We asked our coding 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 coded correctly. Our coding reviewer found the medical records do not include a definitive report validating 15 -21 drug classes, therefore, this service cannot be validated as being performed on September 27, 2019.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 fordrug testing services provided to the enrollee on September 27, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forgenetic testing provided on July 6, 2019.You asked the Plan to pay forgenetic tests. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests were ordered by telemedicine which is a Medicare prohibited action.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forgenetic testing provided on July 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the stair lift repair provided on March 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the stair lift repair. You say that you were not aware of the fact that this was covered by the plan so you did not send it in sooner. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-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 has network providers available who can provide 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 stair lift repair provided on March 5, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by provider on October 11, 2019.You asked the Plan to pay for the air ambulance services. You say that the services were medically necessary.The Plan denied your request. The Plan says the enrollee was not transported to the nearest institution with appropriate facilities for treatment.The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. We looked at the file and Medicare rules. The record shows the enrollee was transported to be closer to family and for further evaluation and treatment. The record does not show the transferring facility did not have adequate facilities to provide the medical services.Based on this information, we decided that Medicare rules for coverage of the air ambulance services have not been met.Therefore, we decided that the Plan does not have to pay for the ambulance services provided by provider on October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on December 6, 2019 by an out of network (OON) provider. You asked the Plan to pay for skilled nursing services. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for skilled nursing services provided on December 6, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve distal clavicle excision for the enrollee.
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 that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has persistent left shoulder pain and dysfunction following a traumatic fall onto his left upper extremity. Functional limitations are documented in activities of daily living. Clinical exam findings are consistent with imaging evidence of rotator cuff tear, labral tear, impingement morphology, and AC joint osteoarthritis. Surgery has been approved to include left shoulder arthroscopic decompression, debridement, and possible biceps tenodesis. Current evidence based medical literature support distal clavicle excision for treatment of this enrollee's AC joint osteoarthritis. The services are therefore reasonable and medically 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 these services have been met. Therefore, we decided that the Plan has to pre-approve distal clavicle excision.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on July 25, 2019.
You asked the Plan to waive the copay for the ambulance transport. You say that if you would have known there was a copay you would have used the ambulance services that you belong to. The Plan denied your request. The Plan says that the claim processed correctly according to the contract and there was no plan error.
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 $350 copay for per one way trip for emergency and non-emergency ambulance services. You have been asked to pay a less than $350 copay for the ambulance transport. The ambulance transport falls within the one way trip for emergency and non-emergency ambulance services benefit category. This means that you have been asked to pay less than 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 copay for the ambulance transport provided on July 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the destruction of a premalignant lesion (17000) provided on October 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the destruction of a premalignant lesion. You say that you have been seeing this patient for years. The Plan denied your request. The Plan says this service was 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 has network providers available who can provide 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 destruction of a premalignant lesion (17000) provided on October 11, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided on October 8, 2019.
You asked the Plan to waive the copayment for an eye exam. You say that you cannot afford the charges. 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 $45 copayment for each visit for services to diagnose and or treat a disease or condition of the eye. You have been asked to pay a $45 copayment for an eye exam. An eye exam falls within the vision 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 an eye exam provided on October 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that due to your medical condition the risk of not reaching medical help in an emergency is raised. Yousay that you called for an ambulance and the responding medic told you that the pain you were experiencing was most likely due to your sinus and allergies. You say that you signed a form by request of the medic but did not know whether a referral was needed to be approved.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 15, 2019. 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 forthe ambulance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed topography (LDCT) scan.
You asked the Plan to pre-approve the requested CT scan. You say that the x-rays performed were not adequate. The Plan denied your request. The Plan says you do not meet the eligibility criteria.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 requested CT scan. Our physician reviewer found that x-rays of the chest were performed and were unremarkable, except for minimal atelectasis to the left lung base. You smoked for 17 years, quitting in 1984. Medicare does not recommend CT chest screening for lung cancer for those older than 77, for those with less than a 30 pack year smoking history, or for those who are symptomatic. The records show that you do not meet any of the above criteria to justify a CT scan, and the x-ray results did not show a suspicious area to require follow-up with CT. Therefore, the requested CT scan is not considered medically reasonable and 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 requested CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a low dose computed topography (LDCT) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on
July 29, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis
(L0650) provided to the enrollee on July 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from November 27, 2019 to November 30, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the hospital almost killed you and you disagree with the charges. 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 $275 copayment per day for days 1-5 per admission for inpatient hospital care. You had an inpatient hospital stay from November 27, 2019 to November 30, 2019. Therefore, you are responsible to pay a $275 copayment for days 1-3 (November 27, 2019 to November 29, 2019). $275 (copayment) x 3 (inpatient days) = $825. You have been asked to pay the total copayment amount of $825 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay from November 27, 2019 to November 30, 2019.
Your quality of care concerns will be forwarded to the appropriate Quality Improvement Organization for review. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 15, 2019 through November 22, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because per CMS, CPT code S9328 is valid. The Plan denied your request. The Plan says CPT code S9328 has a status indicator of I and is not valid for Medicare purposes.
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 code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 15, 2019 through November 22, 2019.