Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the
out of network (OON) provider on November 12, 2019.
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 provided 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 provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide 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 domiciliary or rest home visit (99336) rendered by the out of network (OON) provider on
November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collagen based wound filler (A6010) provided on February 
21, 2020. 
 
You asked the Plan to pay for the wound filler. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted did not include a 
valid physician order; therefore, the billed service cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that a SWO must be communicated to the supplier 
prior to claim submission. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the collagen particles (A6010) have not been met. Specifically, a valid SWO was not 
communicated to the supplier prior to claim submission. The SWO was signed by a Registered Nurse (RN), 
and not by the treating practitioner. A RN is not considered a treating practitioner eligible to sign the SWO to 
fulfill Medicare documentation requirements. Therefore, we decided that the Plan does not have to pay for 
collagen based wound filler (A6010) provided on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) 
rendered by the out of network (OON) provider on January 28, 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 provided 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide 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 subsequent nursing facility care, per day (99308) rendered by the out of network (OON) 
provider on January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Inogen portable oxygen concentrator. 
 
You asked the Plan to pre-approve the requested device. You say that you are unable to move around with the 
current oxygen tank. The Plan denied your request. The Plan says oxygen equipment when purchased, and not 
rented, is never covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Purchased oxygen equipment is statutorily non-
covered. 
 
We looked at the file, and Medicare rules. Based on the information provided, we decided that Medicare rules 
for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Inogen portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the requested items are necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the SNF level of care is not medically necessary for the enrollee at this time. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ForeseeHome age-related macular degeneration 
monitoring system (visual field assessment remote surveillance monitoring device) (0379T) provided July 25, 
2019 to December 22, 2019. 
 
You asked the Plan to pay for the diagnostic testing. You say that you have received many denials on claims 
stating you are not covered per LCD which is incorrect. Your service is outpatient diagnostic testing and you 
are currently out of network with the Plan. The Plan denied your request. The Plan says this service does not 
meet coverage requirements and is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the diagnostic testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the ForeseeHome age-related macular degeneration monitoring system (visual field assessment remote 
surveillance monitoring device) (0379T) provided July 25, 2019 to December 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for self-care management training (97535) provided on March 13, 2020.
You asked the Plan to waive the deductible for the self-care management training. You say that you would like reconsideration because you were not aware of the deductible amount. The Plan denied your request. The Plan says the cost share in the amount of $110.01 was applied correctly as per plan's benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $750. The record shows that the allowed amount for this service is $110.01. This is the amount that was applied towards your deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that your deductible is $750. This cost sharing is a contractual obligation that had not been met at the time the self-care management training was received on March 13, 2020. Therefore, we decided that the Plan does not have to waive the deductible for self-care management training (97535) provided on March 13, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the requested hearing evaluation and hearing aid parts.  
 
You asked the Plan to pre-approve the hearing evaluation and hearing aid parts. The Plan denied your request. 
The Plan says that the services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not responded to our multiple attempts for information. Therefore, 
we decided that the Plan has to pre-approve the requested hearing evaluation and hearing aid parts. 
 
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 physician services provided on December 11, 2019 by an out
of network (OON) 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 prior authorization was not obtained. The
Plan says that these services could be provided in-network.
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. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for physician services provided on December 11,
2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care from January 22, 
2020 through January 24, 2020 provided by an out-of-network provider. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your 
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim 
was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received inpatient hospital care from January 22, 2020 through January 24, 
2020 from an out-of-network provider. The claim was correctly paid and a copayment of $690 was applied. 
Given this was an out-of-network hospital, your estimated copayment responsibility would have been $990 
($495 x 2). In this case the copayment requested is less than the copayment responsibility as outlined in your 
EOC. The service you are appealing was correctly paid under Medicare and your plan. We are still unable to 
adjust the $690 copayment amount. The Plan was able to waive the additional $300 copayment responsibility 
beyond the $690. Your EOC states, "enrollees must pay a $495 copayment per day days 1 to 27 for out-of-
network inpatient hospital care." 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 inpatient hospital care from 
January 22, 2020 through January 24, 2020 provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on October 30, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 Plan has network providers available who can provide the services 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 these services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on October 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic continuous glucose monitor supply allowance 
(K0553) provided March 17, 2020. 
 
You asked the Plan to pay for therapeutic continuous glucose monitor supply allowance. You say that you 
request review of this guideline and reprocessing of the claim as the listed diagnosis code is payable. The Plan 
denied your request. The Plan says the records do not support the service billed. 
 
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 delivery ticket and proof of delivery for the supplies provided in this case. 
Specifically, the billed date of service is March 17, 2020 and the delivery ticket and proof of delivery was 
performed on January 17, 2020. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for therapeutic 
continuous glucose monitor supply allowance (K0553) provided March 17, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health services (90791) 
provided March 3, 2020. 
 
You asked the Plan to waive the copayment for the outpatient mental health services. You say that the 
copayment should be waived. 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 $40 
copayment for Mental Health Office Visits.  
 
You have been asked to pay a $40 copayment for the outpatient mental health services. The outpatient mental 
health services fall within the Mental Health Office Visits 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 outpatient mental health services (90791) provided March 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you called 911 on the date of service
because you were choking on a piece of meat and you could not breathe. You say that when the ambulance
arrived, the paramedics assisted you and you were able to breathe again without any issue. You stated that the
ambulance did not transport you to the hospital and you have now received a bill for the services you received
at your house. You asked the Plan to reconsider providing coverage because you cannot afford the cost of the
bill. 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 June 1, 2019. 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.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible and copayment for an office visit and nasal 
endoscopy provided on February 18, 2020. 
 
You asked the Plan to waive the deductible and copayment for specialist services. You say that you started 
seeing this provider when she was in-network and were not informed that she had gone out-of-network. The 
Plan denied your request. The Plan says the cost-sharing amount you are being charged is correct. 
 
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 $500 
deductible and $10 copayment for out-of-network specialist visit. At the time this claim was processed, 
$172.65 of the $500 deductible had been met. The allowed amount of the claim is $349.04, resulting in a 
deductible amount of $327.35 which meets the $500 total deductible for 2020. The remaining allowed amount 
of the claim is $21.69, resulting in a $10 copayment. Your total cost-sharing obligation is therefore $337.35. 
 
You have been asked to pay $500 deductible and $10 copayment for specialist services. Specialist services fall 
within the Physician/Practitioner Services, Including Doctor's Office Visits 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 deductible and copayment for an office visit and nasal endoscopy provided on 
February 18, 2020.   
 
Your complaint regarding not being told about the change in network status for this provider is considered to 
be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please 
contact the Plan for more information about your grievance.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gastrointestinal tract imaging, intraluminal (eg, capsule 
endoscopy), esophagus through ileum, with interpretation and report (CPT Code 91110) provided to the 
enrollee on January 2, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the enrollee does not have out-of-network benefits. 
 
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 member self-directed for care.  The member's primary care provider did not refer for services. The health 
plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. There is no network deficiency for these services and alternate network 
providers were found. There is an on-line Medicare site to verify eligibility.  There is no referring provider 
listed on the claim. 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. 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 gastrointestinal tract imaging, 
intraluminal (eg, capsule endoscopy), esophagus through ileum, with interpretation and report (CPT Code 
91110) provided to the enrollee on January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on February 4, 2020. You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field. 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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on February 4, 2020.