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

We decided that the Plan does not have to waive the copayment for an MRI scan of a joint of the upper extremity (73221) provided on January 29, 2020.

You asked the Plan to waive the copayment for an MRI scan of a joint of the upper extremity. You say that the requested procedure was an unnecessary test costing a lot of money for Medicare, the Plan, and yourself. The Plan denied your request. The Plan says the correct copayment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for outpatient hi-tech diagnostic procedures. 

You have been asked to pay a $150 copayment for an MRI scan of a joint of the upper extremity. An MRI scan of a joint of the upper extremity falls 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 an MRI scan of a joint of the upper extremity (73221) provided on January 29, 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.

Your complaint about being required to pay for procedures you believe are unnecessary is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture provided on December 8, 2020.

You asked the Plan to pay for the maxillary partial denture. You say that you would like the dentures to be covered. 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 maxillary partial denture provided on December 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan (76377, 73200) provided January 31, 2020.

You asked the Plan to waive the copayment for the diagnostic services. You say that You are very disappointed the way the provider takes care of his patients. In this very difficult time forcing you to pay copay which at this time you have zero income. The Plan denied your request. The Plan says the claim was processed with the correct copayment 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 $150 copay for outpatient hi-tech diagnostic. 

You have been asked to pay $109.17 for the diagnostic services. Since the allowed amount was less than the
copayment amount, you are responsible for the lesser amount. 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 the CT scan (76377, 73200) provided January 31, 2020.

The Qualified Independent Contractor (QIC) read your letter and knows that you may have a quality of care concern. The QIC 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 4 power wheelchair (PWC) and accessories.

You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that Group 4 PWCs are not covered.

The Plan must follow Medicare rules. Medicare rules say that Group 4 PWCs have added capabilities that are not needed for use in the home and will be denied as not reasonable and necessary. 

We looked at 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 a Group 4 power wheelchair (PWC) and accessories.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81404, 81405, 81406) provided August 13,
2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says this service is non-covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented
cardiovascular disease.

We looked at the file and Medicare rules. The cardiovascular risk assessment tests performed are not covered.
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for lab services (81404, 81405, 81406) provided
August 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion or replacement of a spinal neurostimulator pulse
generator or receiver (63685) rendered by the out of network (OON) provider on January 9, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without 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 facility in this case is not a network provider with the Plan. The Plan had network providers available who
could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for
this service. Therefore, we decided that the Plan does not have to pay for the insertion or replacement of a
spinal neurostimulator pulse generator or receiver (63685) rendered by the out of network (OON) provider on
January 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on August 4, 2020.

You asked the Plan to pay for the therapeutic activities. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 

We find that CPT code 97530 is not supported in the medical record. Specifically, the documentation indicates that these services were performed by an occupational therapist assistant in a home health or hospice setting.

This means there is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation unattended (G0283) spinal decompression (S9090) provided August 11, 2020 to August 20, 2020.

You asked the Plan to pay for the chiropractic services. You say that the plan would not cover this non-invasive procedure, but you knew you needed this treatment. You had to pay up front for the 30 treatments needed. The Plan denied your request. The Plan says these services are not covered benefits.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for electrical stimulation unattended (G0283) spinal decompression (S9090) provided August 11, 2020 to August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient dialysis provided by a participating provider on January 11, 2021, to January 29, 2021.

You asked the Plan to waive the coinsurance for outpatient dialysis. You say that you cannot afford this coinsurance. You say that you need to have dialysis for the rest of your life. The Plan denied your request. The Plan says the correct coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for services to treat kidney disease and conditions/in-network/outpatient dialysis. 

The enrollee has been asked to pay a 20% coinsurance of the allowed amount for outpatient dialysis. The total allowed amount is $3,280.50. The total amount you are being asked to pay is $656.10 ($3,280.50 x 20% = $656.10). The correct coinsurance has been applied to the services that were provided. Outpatient dialysis falls within the services to treat kidney disease and conditions/in-network/outpatient dialysis benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for outpatient dialysis provided by a participating provider on January 11, 2021, to January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist telemedicine visit provided by a participating provider on December 14, 2020.

You asked the Plan to waive the copayment for a specialist telemedicine visit. You say that telemedicine visits should have a $0 copayment. 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 $50 copayment for physician/practitioner services/specialist. 

You have been asked to pay a $50 copayment for a specialist telemedicine visit. The correct copayment has been applied to the telelmedicine visit that was provided. A specialist telemedicine visit falls within the physician/practitioner services/specialist 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 a specialist telemedicine visit provided by a participating provider on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and to pay more for the periodontal maintenance (D4910) provided on February 17, 2021.

You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, or pay more for the periodontal maintenance. You say that you believe these services should be covered. The Plan denied your request. The Plan says your annual maximum benefit has been exhausted.

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 Plan offers a $1,500 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the February 17, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and to pay more for the periodontal maintenance (D4910) provided on February 17, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the collection and testing of Covid-19 specimen provided on June 16, 2020.

You asked the Plan to pay for the laboratory testing. You say that the services are for Covid-19 testing. You also say that they are not related to the enrollee's hospice care. 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 enrollee'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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the collection and testing of Covid-19 specimen provided on June 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from November 7, 2020, through December 6, 2020.

You asked the Plan to pay for the continuation of SNF services. The Plan denied your request. The Plan says given that the member has no skilled therapy or skilled nursing needs, the member does not meet Medicare coverage guidelines.

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 pay for the continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was alert with confusion and agitation. She received 1 liter of IVF for poor oral intact on November 14, 2020. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the SNF. By the dates in question, the enrollee was at a minimal to maximal assist level with functional mobility including gait to 25 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

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 continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from November 7, 2020, through December 6, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve cardiac catheterization with ventriculography.

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 a history of exertional chest discomfort which was worse while shoveling snow. He was referred for cardiac nuclear testing which revealed inferior ischemia. He is physically active and has a high risk for significant coronary artery disease given his history of diabetes and has very typical symptoms of angina pectoris. He had a nuclear stress test which revealed inferior territory ischemia. He is on medical therapy. The requested cardiac catheterization and left ventriculography is reasonable and medically necessary at this time. 

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 cardiac catheterization with ventriculography.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) provided February 16, 2021.

You asked the Plan to pay for the office visit. You say that you were told that that the plan would only approve a spinal manipulation. Please reconsider this claim and pay it. The Plan denied your request. The Plan says this service is not covered when rendered by a Chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203) provided February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam with photos (fundus photography) (92250) provided on October 8, 2020.

You asked the Plan to pay for the eye exam with photos. You say that you are on a limited income and cannot afford this bill. The Plan denied your request. The Plan says this type of exam is not covered by Medicare or by the Plan's supplemental vision benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine eye exams. 

We looked at the file and the Plan's rules. An eye exam with photos is not a covered benefit. Therefore, we decided that the Plan does not have to pay for an eye exam with photos (fundus photography) (92250) provided on October 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing (81404, 81407, 81408, 81413, 81238, 81161, 81414, 81411) provided December 7, 2020.

You asked the Plan to pre-approve the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the services at issue are non-covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. 

We looked at the file and Medicare rules. The services provided were cardiovascular risk assessment panels. 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 pre-approve genetic testing (81404, 81407, 81408, 81413, 81238, 81161, 81414, 81411) provided December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3320) provided on July 23, 2020.

You asked the Plan to pay for the endodontic therapy. You say that you feel that this service should be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

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 endodontic therapy (D3320) provided on July 23, 2020.