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

We decided that the Plan does not have to pay for the skilled nursing services provided from August 10, 2020, to September 6, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from June 10, 2020, to November 7, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 10, 2020, to September 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can receive the care you need at home with home care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81225, 81230, 81231, 81328, 81401, 81479).

You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not submitted correctly.

The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so one HCPCS code must be submitted for the panel.

We looked at the file and Medicare rules. The provider billed multiple codes for the panel. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81225, 81230, 81231, 81328, 81401, 81479).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D6259, D4911, D6245, D6740).

You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the dental services provided were not covered services.

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 dental
services (D6259, D4911, D6245, D6740).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work.

You asked the Plan to waive the copayment for the laboratory work. You say that you had an annual physical plus laboratory work. You say the laboratory copayment should not apply because it was waived by the Plan. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $10 copayment for each in-network covered laboratory service.

You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were not charged for the hospital clinic visit which was on the same date of service as the laboratory work. 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 laboratory work.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Nivolumab injection.

You asked the Plan to waive the coinsurance for the Nivolumab injection. You say that you don't feel as though you should have to pay for this. The Plan denied your request. The Plan says you were charged this coinsurance correctly as you had not yet met your out-of-pocket maximum prior to receiving this drug.

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 drugs.

You have been asked to pay 20% coinsurance for the Nivolumab injection. The Nivolumab injection falls within the Medicare Part B 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 Nivolumab injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.

You asked the Plan to pre-approve semi-electric hospital bed. You say that this bed is medically necessary. The Plan denied your request. The Plan says the denial of authorization for this bed is correct, because the record does not show the enrollee has frequent and immediate need for change in body position.

The Plan follows Medicare rules. Medicare rules state that a semi-electric hospital bed is covered for enrollees who meet the criteria for a fixed height hospital bed and also require frequent changes in body position and/or have immediate needs for change in body position.

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 semi-electric hospital bed. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested semi-electric hospital bed. Our physician reviewer found the documentation does not clearly reveal that the enrollee's condition has failed positioning of the bed in ways not feasible for an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for an immediate or frequent change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not 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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued.

You asked the Plan to pay for the compression stockings. You say that you would like this claim reprocessed and approved for payment for medical necessity. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on July 9, 2020.
You asked the Plan to pay for the infectious agent detection. You say that you believe this service should be covered. 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. 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 infectious agent detection by nucleic acid provided on July 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 30, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated very rude and without respect for the situation by the medics. 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 August 30, 2020. 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 for the ambulance services provided on August 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (99601) provided on October 17, 2020.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration bass on the records submitted. The Plan denied your request. The Plan says CPT code 99601 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 99601 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 99601 has a status indicator of I. This means that CPT code 99601 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 (99601) provided on October 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on September 26, 2020, by
an OON provider.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan
denied your request. The Plan says the services were provided without a referral and do not meet criteria for
OON coverage.
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 office visit (99213) provided on September 26,
2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, two first intraoral periapical x-rays, and add tooth to existing partial denture provided on September 24, 2020 by an OON provider.
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-rays, and add tooth to existing partial denture. You say that you thought that the dental office you went to would be in-network. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that you contacted the Plan and were given a provider who was in-network at a different location and practice.
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, you are responsible for 100% of the cost for dental services received from an OON provider. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, two first intraoral periapical x-rays, and add tooth to existing partial denture provided on September 24, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee.

You asked the Plan to pay for this transport. You say that this claim should be paid due to COVID-19 exceptions announced by Medicare. The Plan denied your request. The Plan says Medicare coverage criteria for transport are not met. Maximus upheld the Plans denial. New information was received, and the case was reopened.

Our Medical Director looked at the case file and the reopen request. The medical records show the enrollee was a 68-year-old woman who was transported by ambulance to a physician's office for an appointment because of bed sores on her tailbone. The enrollee had bilateral weakness of her upper and lower extremities. Vital signs were normal. The enrollee was transferred to the ambulance and was transported to the office. The provider assessed the bed sores and rebandaged them. While CMS has temporarily expanded the list of allowable destinations for ambulance transports to include physician's offices, the general coverage rules for ambulance transport still apply. The documentation does not support that the another means of transport, such as a stretcher van, was contraindicated for the enrollee at the time of transport. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on the date of transport. The documentation does not support that the ambulance transport was medically reasonable and necessary for the enrollee in this case. There are not sufficient grounds for reversing the determination in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this transport have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for office visit. You say that you are appealing with supporting documentation. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 medical services provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5298).

You asked the Plan to pay for the hearing aids. You say that the hearing aids were medically necessary. The Plan denied your request. The Plan says hearing aids obtained out-of-network are not covered.

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 hearing aids only when obtained from a plan-contracted supplier.

We looked at the file and the Plan's rules. The record shows the hearing aids were not obtained from a network-contracted vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5298).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for sclerotherapy provided from May 26, 2020, to July 6, 2020.
You asked the Plan to waive the copayments for sclerotherapy. You say that you disagree with how the charges were processed and feel that you should only owe specialist copayments. 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 $200 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The record shows that you received sclerotherapy at an outpatient hospital facility from May 26, 2020, to July 6, 2020, for a total of 7 visits. Sclerotherapy is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $200 copayment per each visit. The total amount you owe is: $200 (copayment) x 7 (surgery services) = $1,400. You have been asked to pay the total copayment amount of $1,400 for sclerotherapy. Sclerotherapy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments for sclerotherapy provided from May 26, 2020, to July 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the review has determined that the record did not show that the enrollee's necessary hospital care would span two midnights.

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 not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for home health services provided on July 24, 2020, July 25, 2020 and July 26, 2020 by an out of network provider.
You asked the Plan to reimburse you for the home health services. You say that you were unaware of checking to see if they were certified as a Medicare provider. The Plan denied your request. The Plan says you obtained home health services from a provider who does not participate with Medicare.
Medicare rules say that no Medicare payment may be made to a beneficiary for services provided directly by a provider who is not eligible to take Medicare payment. The services at issue in this appeal were provided by a provider not certified by Medicare. We found no exception that would require the Plan to reimburse you for these items/services. Therefore, we decided that the Plan does not have to reimburse you for home health services provided on July 24, 2020, July 25, 2020 and July 26, 2020 by an out of network provider.