Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from July 5, 2020, to July 6, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that the services were medically necessary.ThePlan denied your request. The Plan says that the services should be re-billed as observation.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the patient arrived at the Emergency Department with 5 days of epigastric abdominal pain with nausea, anorexia, weakness, and weight loss as well as tarry stools. The CT performed showed inflammation of the proximal duodenum consistent with ulcer andpossible perforation. The patient was diagnosed with duodenal ulcer without hemorrhage or perforation. Due to the results of the CT scan, presenting symptoms, and age of the patient the urgency to perform EGD and admit the patient was warranted and due tothe complexity was expected to cross 2 midnights, according to the records.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from July 5, 2020, to July 6, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case againif 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for themyocardial perfusion imaging, tomographic (SPECT) (78452) provided April 15, 2020.You asked the Plan to waive the copayment for thediagnostic services. You say that you should not have to owe this amount, especially since you were not fully informed so you could have the option to opt out.The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied per the Evidence of Coverage.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 $200 copay for nuclear stress tests. You have been asked to pay $200 copay for the diagnostic services. The diagnostic services fall within the Outpatient diagnostic tests and therapeutic services and supplies 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 themyocardial perfusion imaging, tomographic (SPECT) (78452) provided April 15, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmology service provided on September 4, 2020.
You asked the Plan to waive the copayment for the ophthalmology service. You say that you were charged a copayment for the office visit and a charge for refraction. The Plan denied your request. The Plan says refraction is a noncovered Medicare benefit when performed during a medical office visit and you were charged the copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for Vision Care. You have been asked to pay a $30 copayment for the ophthalmology service. The ophthalmology service falls within the Vision Care benefit category. The Explanation of Benefits shows the refraction is included in the exam payment. 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 ophthalmology service provided on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for the specialist office visit (99213) provided.

You asked the Plan to waive the co payment for the office visit. You say that this appointment was for your husband and should have been billed under his account.The Plan denied your request. The Plan says medical records show that you had an appointment with a cardiologist. Office visits with a specialist have a $30 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 $30copayment for specialist office visits. 

You have been asked to pay a $30 copayment for a specialist office visit. A cardiologist is a specialty physician. Medical records were provided detailing an office visit. 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 fora specialist office visit (99213) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wrist hand orthosis provided on August 28, 2020.You asked the Plan to pay forthe wrist hand orthosis (L3916). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says the orthosis is not supported in the medical records received.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 pay for the wrist hand orthosis (L3916). Our reviewer says that the orthosis is not medically necessary. Our physician reviewer found the enrollee's chief complaint was Hand/Wrist Right pain. The documentation in the case file does not support that the requested wrist/hand orthosis was medically reasonable and necessary for the enrollee in this case. An appropriate history and a physical examination of the wrist would reasonably be required to adequately assess whether the wrist/hand orthosis was medically reasonable and necessary. The documentation does not support that the wrist/hand orthosis was medically reasonable and necessary in this case, as there is an inadequate history, and 
insufficient documentation of a credible physical examination of the wrist.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 wrist hand orthosis (L3916) have not been met.Therefore, we decided that the Plan does not have to pay forthe wrist hand orthosis provided on August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5261) provided.

You asked the Plan to pay for hearing aids. You say that this item should be covered.The Plan denied your request. The Plan says you have exceeded the Plan's maximum benefit.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for up to $1000 combined in and out-of-network maximum benefit for batteries and each hearing aid(s)(all types) up to 1 per ear every 3 years. 

We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Specifically, the Plan paid $2,000 for this item which is over the Plan's maximum benefit of $1,000. You are responsible for any cost over the Plan's maximum benefit.Therefore, we decided that the Plan does not have to pay for hearing aids (V5261) provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe shoulder arthroscopy rendered on June 23, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 29823 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 29823 is surgical arthroscopy of shoulder with extensive debridement.We find that CPT code 29823 is not supported in the medical record. Specifically, the operative report does not contain documentation of a surgical shoulder arthroscopy with extensive debridement. 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 forthe shoulder arthroscopy rendered on June 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Nitroglycerin 0.4mg tablet and Aspirin 81mg tablet (A9270).
You asked the Plan to pay for Nitroglycerin and Aspirin. You say that the items were medically necessary. The Plan denied your request. The Plan says drugs given in a hospital outpatient setting that are considered self-administrable are not covered under Medicare Part B. The member can pay the charges and submit a claim under the Part D benefits for payment/reimbursement consideration.
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 pay for Nitroglycerin 0.4mg tablet and Aspirin 81mg tablet (A9270).
Benefits for Nitroglycerin and Aspirin 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the tissue exam (88305) provided on August 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for tissue exam. You say that the service was medically necessary. 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 tissue exam (88305) provided on August 25, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this claim was not billed with the appropriate place of service code.

The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory place of service code. The record indicates that the face-to-face service and specimen collection was rendered in an office setting.Therefore, we decided that the Plan does not have to pay for the laboratory services provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an adjacent tissue transfer or rearrangement (14040) provided on April 15, 2020. You asked the Plan to pay for an adjacent tissue transfer or rearrangement. You say that this was medically appropriate and necessary. The Plan denied your request. The Plan says this code 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 14040 is adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less. 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 pay for an adjacent tissue transfer or rearrangement. Our reviewer says that this code is not supported in the records. Our physician reviewer found the operative report does not include sufficient documentation to verify an adjacent tissue transfer was performed. The operative report only states that "the wound was then closed with a banner flap in order to obtain the least amount of tension on the wound closure." We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an adjacent tissue transfer or rearrangement have not been met. Therefore, we decided that the Plan does not have to pay for an adjacent tissue transfer or rearrangement (14040) provided on April 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe amalgam (D2160) provided on September 3, 2020.You asked the Plan to pay forthe amalgam. You say that you were not advised that your coverage had changed.The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that you were not enrolled in the optional dental rider for the 2019 and 2020 plan years.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coveragerules 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 forthe amalgam(D2160) provided on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 53 of the plan's 2020 Evidence of Coverage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling (D4342), personal protective equipment (PPE) (D1999), topical fluoride (D1206), prophylaxis (D1110) and periodontal evaluation (D0120) provided on September 11, 2020.
You asked the Plan to pay for periodontal scaling, PPE, topical fluoride, prophylaxis and periodontal evaluation. You say that the services should be covered. The Plan denied your request. The Plan says services obtained through providers who have opted out of Medicare 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. Specifically, you obtained services from a provider who has opted out of Medicare. This means the services are not covered. Therefore, we decided that the Plan does not have to pay for periodontal scaling (D4342), personal protective equipment (PPE) (D1999), topical fluoride (D1206), prophylaxis (D1110) and periodontal evaluation (D0120) provided on September 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from October 1, 2020, to October 5, 2020.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you do not think you should pay for the poor quality of care you allegedly received. The Plan denied your request. The Plan says the copayment processed correctly in this case.
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 $492 copayment per day for days 1-4, $0 copayment for each additional day for inpatient hospital care. You have been asked to pay a total cost share of $1968 for the inpatient hospital care (4 days x $492 copayment). The services provided fall 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 the inpatient hospital care provided from October 1, 2020, to October 5, 2020.
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 provide additional reimbursement forthe office visit (99202) provided at an urgent care on June 10, 2020.You asked the Plan to provide additional reimbursement forthe urgent care office visit. You say that you should be provided additional reimbursement.The Plan denied your request. The Plan says the cost share was calculated 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 Urgently needed services. You have been asked to pay a $50 copayment for an urgent care office visit. Urgent care office visits fall within the Urgently needed services benefit category. In addition, the Plan contract states that if you have already paid more than your share of the cost of the service provided by an out-of-network provider, the Plan will determine how much you owed and pay you back for the Plan's share of the cost. This means in addition to our copayment you are responsible for the difference between the amount you paid and the Plan's allowed amount for the service. The total amount you are being asked to pay is $180.92($205 total cost -$74.08 allowed amount = $130.92+ $50 copayment =$180.92). Therefore, 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 provide additional reimbursement forthe office visit (99202) provided at an urgent care on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on April 27, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the services provided on April 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for personal protective equipment (PPE) (D1999) provided on November 10, 2020.
You asked the Plan to pay for PPE. You say that the service should be covered. The Plan denied your request. The Plan says it is 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 pay for personal protective equipment (PPE) (D1999) provided on November 10, 2020.