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

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by the provider from August 9, 2019 to October 28, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that The Plan should pay this claim.The Plandenied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from August 9, 2019 to October 28, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on February 5, 2019.You asked the Plan to waive the copayment for an ambulance trip. You say that you suffered from medical malfeasance and should not be responsible for the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for ambulance services. You have been asked to pay a $275 copayment for an ambulance trip. An ambulance trip falls within the ambulance 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 an ambulance trip provided on February 5, 2019.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 forthe resin based composite for 2 surfaces on posterior teeth (D2392) for tooth # 15, and the resin based composite for 3 surfaces on a posterior tooth (D2393) for teeth # 12, 13, and 14 provided by the provider on February 13, 2019.You asked the Plan to pay forthe dental services. You say that you were advised of the $500 maximum dental benefit. You also say that you were not advised that fillings were not a covered service.The Plan denied your request. The Plan says resin based composites are not listed as 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 resin based composites are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe resin based composite for 2 surfaces on posterior teeth (D2392) for tooth # 15, and the resin based composite for 3 surfaces on a posterior tooth (D2393) for teeth # 12, 13, and 14 provided on February 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe oxygen equipment you received on June 4, 2019.You asked the Plan to waive the cost share forthe provided equipment. You say that it's getting too hard to pay the copays every month.The Plan denied your request. The Plan says the DME benefit has been applied 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 20% coinsurance for durable medical equipment and related supplies. The file shows that you were charged $28.11 for an oxygen concentrator, and $5for a portable gaseous system. This is a 20% coinsurance for the provided equipment. The equipment falls within the durable medical equipment and related 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 cost share forthe oxygen equipment you received on June 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on May 7, 2019.You asked the Plan to waive the copayment forlaboratory services. You say that the basic lab work should be covered at no extra cost. You say that you have never had to pay for this in the past.The Plan denied your request. The Plan says the copayment applied 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 $10 for laboratorytests. You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 forlaboratory services provided on May 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350) provided on August 28, 2019.You asked the Plan to pay for the dental services. You say that you were in a lot of pain. You also say that you were unable to chew and sleep due to the pain.The Plan denied your request. The Plan says the 2D photographic imaging is not listed as 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 2D photographic imaging is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350) provided on August 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forgenetic testing services provided to the enrollee on April 10, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe records from the treating provider were obtained, and they do not indicate that the enrollee has the diagnoses reported by the laboratory.
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 pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the available medical records in the case file consist of a Molecular Diagnostics Requisition, a Pharmacogenetic Test Order, a Clinical Summary, a Your Home Advantage In-Home Wellness Visit Summary, and the results of the molecular genetic hereditary predictive testing. It has not been demonstrated that this testing would impact the health of the enrollee. The available documentation in the case file does not support that the molecular genetic hereditary predictive testing (RESPONSE Pharmacogenomic Testing) was medically reasonable and necessary for the enrollee 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 the services have not been met.Therefore, we decided that the Plandoes not haveto pay forgenetic testing services provided on April 10, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay forthe abutment supported crown. We decided that the Plan does not have to pay forthe custom fabricated abutment. You asked the Plan to pay forthe abutment supported crown. You say that although the tooth is now attached to an implant, the crown should also be covered.The Plan says that these are not covered benefits.We decided that the Planhas to pay forthe abutment supported crown. The Plan contract says that porcelain or ceramic crowns over an implant body are a covered benefit.Therefore, we decided that the Plan has to pay forthe abutment supported crown. We also decided that the Plandoes not have to pay forthe custom fabricated abutment.Your contract with the Plan clearly says thata surgical placement of an implant body is covered to replace a single missing natural anterior (front) tooth.Tooth #30 is a molartooth. Therefore, we decided that the Plan does not have to pay forthe custom fabricated abutment.
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 Plandoes not haveto pay forphysician services provided by "the provider" on May 30, 2019.You asked the Planto pay forthe services. You say that you are extremely sensitive and need to see doctors who are gentle, understanding, and work in a relaxed office environment.The Plandenied your request. The Plansayspayment is denied as this is a privately contracted provider.The Plan must followMedicare 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.Theservices at issue in this appeal were provided in a non-urgent, non-emergent situation by the rendering provider. This provider has opted out of the Medicare program. The file shows that the rendering provider entered into a private contract with you regarding payment.Therefore, we decided that the Plandoes not haveto pay forphysician services provided by "the provider" on May 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia provided on April 23, 2019 by the out of network provider.You asked the Plan to pay for the anesthesia services. You say that the provider relies on the facility to obtain the necessary authorizations. You also say that the provider does not have control over whether or not they are obtained.The Plan denied your request. The Plan says authorization was not obtained before the services were rendered to the enrollee. The Plan also says the services were not urgent or emergent.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 provider in this case is not a network provider with the Plan. The facility where the enrollee received the service is not a network provider either. 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 anesthesia provided on April 23, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on March 8, 2019 and June 13, 2019.
You asked the Plan to waive the copayment for lab services. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 copayment for lab services. You received lab services provided on March 8, 2019 and June 13, 2019. Therefore, you are responsible to pay a $5 copayment per each lab service. The total amount you owe is: $10.00. You have been asked to pay the total copayment amount of $10.00 for lab services. Lab 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 lab services provided on March 8, 2019 and June 13, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit August 25, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that that this ER copayment should be waived because this visit was within three days of your previous emergency room visit. The Plan denied your request. The Plan says you have been charged 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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you were treated in the emergency room and not admitted as an inpatient on August 25, 2019.
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 emergency room visit on August 25, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Room services (99284) provided on November 2, 2018.
You asked the Plan to pay for the Emergency Room services. You say that the member was seen twice on the same date of service by separate providers. The Plan denied your request. The Plan says 99284 is the Column II code to 99285 which was processed and paid.
The Plan must follow Medicare rules. Medicare rules say that If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be
reported unless the evaluation and management services are for unrelated problems. In this case, we have confirmed that code the Emergency Room services has a bundled relationship with code 99285 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for Emergency Room services (99284) provided on November 2, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing of 15-21 drug classes provided on July 3, 2019.You asked the Plan to pay for the definitive drug testing. You say that this sample was received from the treating provider and testing could not be delayed. This claim should be paid.The Plan denied your request. The Plan says the order does not specify which drugs should be tested and the lab report does not support that between 15 and 21 drug classes were tested.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that lab services may be covered when ordered by the treating provider.In this case, the lab requisition form only indicates confirmation testing being requested for the prescribed medication, oxymorphone. It is not clear from the order whether additional opiates are requested for testing. In addition, the lab report does not clearly show 15 or more drug classes being tested, which does not support the code billed.Therefore, we decided that the Plan does not have to pay for the definitive drug testing of 15-21 drug classes provided on July 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic testing supplies provided from July 28, 2019 to October 16, 2019.You asked the Plan to pay for the diabetic testing supplies. You say that this claim should be paid.The Plan denied your request. The Plan says the documentation does not contain a valid proof of delivery.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. The delivery ticket does not document the tracking number for the package and the delivery confirmation does not clearly indicate the address nor the package delivered.Therefore, we decided that the Plan does not have to pay for the diabetic testing supplies provided from July 28, 2019 to October 16, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from April 30, 2019 to June 28, 2019.You asked the Plan to pay for the home health services. You say that this claim should be approved for payment.The Plan denied your request. The Plan says home health claims must include a Q-code on the date of the first visit to correspond to the location in which the services were provided. Since this is not present, the claim is not payable.The Plan must follow Medicare rules. Medicare rules say that Q-codes describing the location in which the home health care is rendered must be included on the claim.In this case, the claim does not list any of the three Q-codes required for home health billing.Therefore, we decided that the Plan does not have to pay for the home health services provided from April 30, 2019 to June 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wrist/hand orthosis (L3916) provided by "the provider". February 22, 2019.You asked the Plan to pay forthe orthosis. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says there is no established relationship between the enrollee and the ordering physician and no claims was submitted for an evaluation and management services.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) locatedin a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for anin-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay forthe wrist/hand orthosis (L3916) provided by "the provider". February 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on August 29, 2019.You asked the Plan to pay for the shingles vaccine. You say that the pharmacy said the cost would be covered.The Plan denied your request. The Plan says your health plan does not cover the Part D drug.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine.Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on August 29, 2019.Benefits for the shingles vaccine 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 95874) provided to the enrollee on July 11, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this is an add-on code.The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that add-on codes can only be reported in addition to a primary procedure. When the CPT Manual identifies specific primary codes, the add-on code shall not be reported as a supplemental service for other HCPCS/CPT codes not listed as a primary code. CPT 95874 is an add-on code and was not reported with an appropriate primary procedurecode. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe services (CPT 95874) provided to on July 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 27, 2019 by out of network provider.You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained; therefore, payment has been correctly denied.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The referring provider is also out-of-network.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 on June 27, 2019 by out of network provider.