Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator purchased on May 30, 2020.
You asked the Plan to pay for these services. You say that you would like reimbursement. The Plan denied your request. The Plan says purchased equipment is not covered.
The Plan must follow Medicare rules. The rules say that reimbursement for oxygen equipment is limited to 36 monthly rental payments. We looked at the file and Medicare rules. The file shows that you purchased the portable oxygen concentrator. Medicare pays for 36 months of rental equipment only. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the portable oxygen concentrator purchased on May 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 24, 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 procedure code 88341 is not supported.
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 88341 is immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure). We find that CPT code 88341 is not supported in the medical record. Specifically, the add-on code was not billed with a required primary procedure code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage of abscess services coded 10061 provided on July 4, 2020. You asked the Plan to pay for the incision and drainage of abscess 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 supported by the documentation.
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 10061 is incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple. We find that CPT code 10061 is not supported in the medical record. Specifically, the documentation submitted does not indicate that incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple was performed. In addition, there is a more appropriate code to be billed for the services provided. Based on this information, we decided that Medicare rules for coverage of the incision and drainage of abscess services have not been met. Therefore, we decided that the Plan does not have to pay for the incision and drainage of abscess services coded 10061 provided on July 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating hospital on July 25, 2020, to August 7, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that these services did not happen. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $285 copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care. You have been asked to pay a $285 copayment per day for days 1-6. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,710 ($285 x 6 days = $1,710). 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 provided by a participating hospital on July 25, 2020, to August 7, 2020.
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on July 28, 2020.
You asked the Plan to pay for the periodontal maintenance. The Plan denied your request. The Plan says this
service is 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 pay for the
periodontal maintenance provided on July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture with limited field of view (D0380) and the consultation (D9310) provided on October 1, 2020.
You asked the Plan to pay for the dental services. You say that you cannot afford to have your 3 teeth extracted. You also say that you need help. The Plan denied your request. The Plan says the cone beam CT capture is not listed as a covered service. The Plan says the consultation is not listed as a covered service either. The Plan also says that any services that are not listed 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 pay for the cone beam CT capture with limited field of view (D0380) and the consultation (D9310) provided on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmic ultrasound (76512) provided on October 6, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you have never been charged a copayment for this service before. The Plan denied your request. The Plan says you were seen for both an office visit and an ultrasound, and ultrasounds have a $40 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 $40 copayment for outpatient diagnostic x-rays and ultrasounds. You have been asked to pay a $40 copayment for the ultrasound. An ultrasound falls within the outpatient diagnostic x-rays and ultrasounds 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 ophthalmic ultrasound (76512) provided on October 6, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the drug test (G0483) provided on June 12, 2020.
You asked the Plan to pay for the drug test. You say that you would like reconsideration based on the records submitted The Plan denied your request. The Plan says that the record supports that 10 drug classes were tested.
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 G0483 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; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is supported in the record. Specifically, the record shows that 22 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the drug test have been met. Therefore, we decided that the Plan has to pay for the drug test (G0483) provided on June 12, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion supplies (E0781, A4222) provided from August 7, 2019, to October 9, 2019.
You asked the Plan to pay for infusion supplies. You say that these items should be covered. The Plan denied your request. The Plan says these items are bundled into the facility payment.
The Plan must follow Medicare rules. Medicare rules say that when medical and surgical supplies are provided incident to a physician's service by a hospital outpatient department, the HCPCS codes for these items should not be reported because these items represent supplies.
We looked at the file and Medicare rules. The record indicates that the supplies at issue were provided incident to chemotherapy infusions in an outpatient hospital. Based on this information, we decided that Medicare rules for coverage of infusion supplies have not been met. Therefore, we decided that the Plan does not have to pay for infusion supplies (E0781, A4222) provided from August 7, 2019, to October 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital inpatient care services (99222) provided May 20, 2019.
You asked the Plan to pay for the inpatient services. You say that you did not receive proper notice of this enrollee's benefit determination. You depend on the facility for timely notification of patient's health insurance coverage. The Plan denied your request. The Plan says claim submitted after timely filing limitations.
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 inpatient services was not filed until September 24, 2020. 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 initial hospital inpatient care services (99222) provided May 20, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management, less than 30
minutes, provided on July 2, 2020.
You asked the Plan to pay for the physician service. You say that this claim was previously paid. You also say
that payment was retracted with no reason given. The Plan denied your request. The Plan says the enrollee's
claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on
the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the
provider's responsibility to verify the member's coverage before rendering services and to know proper billing
procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the hospital discharge day management, less than 30 minutes,
provided on July 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the alcohol and/or drug services; sub-acute detoxification
(residential addiction program inpatient) (H0010) provided on July 26, 2020, by an out-of-network (OON)
provider.

You asked the Plan to pay for the inpatient detoxification services. You say that there was no time to submit a
prior authorization. It happened overnight that you were put into the facility. You were under the impression
this was paid for. You're being billed over $30,000. The Plan denied your request. The Plan says enrollee's
must receive their medical services from an in-network provider with the exception being urgent or emergent
services. Non-emergent services with non-contracted providers require prior authorization before services
being rendered.

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 alcohol and/or drug services; sub-acute
detoxification (residential addiction program inpatient) (H0010) provided on July 26, 2020, by an out-ofnetwork
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), the bone replacement graft for ridge preservation (D7953), and the 2 extractions (D7140) provided on August 12, 2020.

You asked the Plan to pay for the dental services. You say that you had 2 teeth extracted and x-rays done. You say that periodontics surgery is a covered service at 50% after the $100 deductible has been met. You also say that you would like to appeal my claim and have the payment reviewed. The Plan denied your request. The Plan says guided tissue regeneration is not listed as a covered service. The Plan says that bone replacement graft for ridge preservation is not listed as a covered service. The Plan says that extractions have a 50% coinsurance of the covered plan allowance after the $100 annual deductible is met. The Plan also says that the provider in this case is out of network and you may pay more for dental services that you receive out of network.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the guided tissue regeneration and bone replacement graft are not among those covered under this benefit. The record shows that prior to receiving these services, the none of the deductible had been paid. You are responsible for the full amount of the covered service until the deductible has been met. Additionally, dental services that you receive out of network may cost more as out of network providers are allowed to bill you for the difference between what they bill and what the Plan pays. Therefore, we decided that the Plan does not have to pay for the guided tissue regeneration (D4266), the bone replacement graft for ridge preservation (D7953), and the 2 extractions (D7140) provided on August 12, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy rendered on March 4, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct POS code. 

We looked at the file and Medicare rules. The provider billed code 45380 with POS code 11 for an office setting; however, the file shows that the services were performed in an ambulatory surgical center and should be billed with POS code 24. Therefore, we decided that the Plan does not have to pay for the colonoscopy rendered on March 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pantoprazole.

You asked the Plan to pre-approve Pantoprazole. You say that it is medically necessary for the enrollee to be treated with this medication. The Plan denied your request. The Plan says this drug is not covered under the enrollee's plan under any normal circumstances.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pantoprazole.

Benefits for Pantoprazole may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiation therapy services (77412) provided from July 1, 2020 to July 31, 2020.
You asked the Plan to waive the copayment for radiation therapy. You say that you cannot afford the cost-share. The Plan denied your request. The Plan says there is a $60 copayment for each session of radiation therapy, and you had 21 sessions in July of 2020.
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 $60 copayment for therapeutic radiology services. You have been asked to pay a $60 copayment for each session of radiation therapy ($60 x 21 sessions = $1,260). Radiation therapy falls within the therapeutic radiology 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 radiation therapy services (77412) provided from July 1, 2020 to July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 27, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, the enrollee must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis services and cases in which our plan authorizes use of out-of-network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 physician's services. 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 physician's services provided on January 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed x2 (37227), angiography, extremity, bilateral, radiological supervision and interpretation x2 (75716) and angiography, extremity, unilateral, radiological supervision and interpretation x1 (75710) for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that these services in the setting of normal ABI and no symptoms is not medically needed.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The patient has normal ABIs with essentially normal toe pressures. This is inconsistent with leg pain at rest due to ischemia. Additionally, as noted by the health plan, the patient does have a history of back issues which could explain the patient's lower extremity complaints. Also, as noted by the health plan, there has been no exercise ABI or duplex examination to suggest the presence of a significant symptomatic arterial lesion. There are also inconsistencies in the medical record with documentation that the patient denies pain/cramping in the legs after exercise. Our physician reviewer found that the enrollee's condition does not meet criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed x2 (37227), angiography, extremity, bilateral, radiological supervision and interpretation x2 (75716) and angiography, extremity, unilateral, radiological supervision and interpretation x1 (75710) for the enrollee.