Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy provided on July 10, 2019 and July 17, 2019.You asked the Plan to waive the copayments for physical therapy. You say that you went to physical therapy but they didn't serve your needs. You say that you cannot afford it. The Plan denied your request. The Plan says the copayments 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 $30 for each Medicare-covered physical therapy visit.You have been asked to pay a $30 copayment for each physical therapy visit. The total amount you owe is $60 ($30/visit x 2 visits = $60). Physical therapy falls within the "Outpatient rehabilitation 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 copayments for physical therapy provided on July 10,2019 and July 17, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services (99239) provided July 18, 2019 You asked the Plan topay forthe physician services. You say that the services were medically necessary and properly billed.The Plan denied your request. The Plan says original Medicare must be billed for the services at issue.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 forphysician services (99239) provided July 18, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the advanced care planning rendered to the enrollee by the doctor.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99497 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. We find that CPT code 99497 is not supported in the medical record. Specifically, there is no documentation of discussion between the provider and patient for advance care planning services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the advanced care planning rendered to the enrollee by the doctor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 17, 2018 by an out of network provider.
You asked the Plan to pay for outpatient lab work. You say that these services were medically necessary. The Plan denied your request. The Plan says they have correct denied payment for the service in question.
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 Plan says these services were not medically necessary. 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 October 17, 2018 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided by an out-of-network provider on August 21, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you are appealing for reconsideration of the denied charges.
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. Review of the file show that you received a periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided by an out-of-network provider. Your EOC clearly states, enrollees must pay 50% for out-of-network exams and prophylaxis (cleaning). Therefore, you are asked to pay 50% for the exam and cleaning. Therefore, we decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided by an out-of-network provider on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe coinsurance forthe psychiatric evaluation provided on July 26, 2018.You asked the Plan to waive the coinsurance forthe psychiatric evaluation. You say that you would like the Plan to cover these charges because this is the only provider thatcan treat the enrollee. 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). The enrollee's contract with the Plan clearly says that they must pay 50% for of the Medicare-allowed amount for each out-of-network Medicare-covered individual or group therapy visit.The enrollee has been asked to pay $57.58 which is 50% of the allowed amount for the psychiatric evaluation. The allowed amount is $115.15. ($115.15 x 50% = $57.58). The psychiatric evaluation falls within the "Outpatient mental health care" 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 forthepsychiatric evaluation provided on July 26, 2018.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 30, 2019 through August 1, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record shows that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation 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 been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from July 30, 2019 through August 1, 2019.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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound provided by "the Hospital" on August 15, 2019.You asked the Plan to waive the copayment foran ultrasound. You say that you have never had to pay for an ultrasound before.The Plan denied your request. The Plan says the correct copayment has been applied to the service that was provided.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 $75 copayment for outpatient diagnostic tests/diagnostic radiology services. You have been asked to pay $27.29 which is less than your copayment amount of $75 for an ultrasound. An ultrasound falls within the outpatient diagnostic tests/diagnostic radiology 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 foran ultrasound provided by "the Hospital" on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Gel-One injection rendered to you on June 4, 2019.
You asked the Plan to waive the coinsurance for these services. You say that you were advised by the facility there would be no further charges. The Plan denied your request. The Plan says the coinsurance was 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 15% coinsurance for Part B drugs that are administered by a provider.
Review of the file shows that you presented to your provider on June 4, 2019 and received a Gel-One injection. You have been asked to pay a 15% coinsurance for these services, for a total of $144.61. These services fall within the Part B drugs that are administered by a provider 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 Gel-One injection rendered to you by your provider on June 4, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 30, 2019 by out-of-network provider. You asked the Plan to pay for the out-of-network services. You say that the test is the only way of making sure you had SIBO.The Plan denied your request. The Plan says your plan requires covered services from a contracted plan provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for carefrom 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 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 out-of-network services.Therefore, we decided that the Plan does not have to pay for the medical services provided on August 30, 2019 by out-of-network provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from March 22, 2019 through April 5, 2019.
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 you are appealing your cost-share responsibility for the services you received.
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 shows that you received inpatient hospital care provided from March 22, 2019 through April 5, 2019. You were asked to pay a $325 copayment per day from March 22, 2019 through March 26, 2019, days 1-5 of your inpatient stay. There were no copayment charges from March 27, 2019, day 6 of your inpatient hospital care until your day of discharge April 5, 2019. Per your contract there is a $325 copayment per day required for days 1-5. 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 provided from March 22, 2019 through April 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran intravascular doppler measurement (93571) provided on July 8, 2019.You asked the Plan to pay forthe intravascular doppler measurement. You say that the service was provided and payment should be rendered.The Plan denied your request. The Plan says based on the documentation provided, the claim was processed correctly.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 93571 is an intravascular doppler measurement.We asked our codingreviewer 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 intravascular doppler measurement. Our coding reviewer says that the service is not supportedby the medical records provided. Our MAXIMUS Coding reviewer found CPT code 93571 is not supported by the medical record. The documentation does not 
contain evidence that an intravascular doppler measurement was taken during the angiography.We looked atthis coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the intravascular doppler measurement have not been met.Therefore, we decided that the Plan does not have to pay foran intravascular doppler measurement (93571) provided on July 8, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forA4253, A4259, A4256 and A4235 provided to the enrollee from August 4, 2019 through October 23, 2019.You asked the Plan to pay for the DME. You say that the claim should be paid.The Plan denied your request. The Plan says the services are not supported.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The Delivery Ticket submitted did not include the carrier's tracking number, nor did the Proof of Delivery include an order number or details to corroborate the Delivery Ticket submitted.Therefore, we decided that the Plan does not have to pay for A4253, A4259, A4256 and A4235 provided to the enrollee from August 4, 2019 through October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (CPT Code S9328) provided to the enrollee.
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 Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Medicare guidance says procedure code S9328 has a status code of "I". You can find this guidance in the 2019 Year National Physician Fee Schedule Relative Value File July Release. Medicare guidance says status code "I = Not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (CPT Code S9328) provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for CPAP device (CPT Code E0601) purchased from an out-of-network provider.
You asked the Plan to pay for the CPAP device. You say that your CPAP machine stopped working and you were advised it would take four to six weeks to get the machine replaced. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CPAP device have not been met. The amount purchased was more than the $150 allowed by Medicare and this is not an accessory to the CPAP machine therefore the plan has upheld the original denial. Purchased equipment is not covered by the plan. The plan only covers rented durable medical equipment or items under $150. Therefore, we decided that the Plan does not have to pay for CPAP device (CPT Code E0601) purchased from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forA4253, A4259, A4256 and A4235 provided to the enrollee from August 13, 2019 through November 1, 2019.You asked the Plan to pay for the DME. You say that the claim should be paid.The Plan denied your request. The Plan says the services are not supported.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The Delivery Ticket submitted did not include the carrier's tracking number,nor did the Proof of Delivery include an order number or details to corroborate the Delivery Ticket submitted.Therefore, we decided that the Plan does not have to pay forA4253, A4259, A4256 and A4235 provided to the enrollee from August 13, 2019 through November 1, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care (99308) provided by out ofnetwork provider, "the nurse practitioner" on August 8, 2019.You asked the Plan to pay forthese services. You say that the enrollee has been a resident of "the facility" for years and has been under this practitioner's care as well. Neither the facility nor the nurse practitioner were aware of the enrollee's recent insurance change.The Plan denied your request. The Plan says the services are not authorized because "the nurse practitioner" is a non-network provider who does not work with the member's health plan. The member was referred by her non-participating nursing facility. The member's primary care physician did not refer for these 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. 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 services 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 forthe subsequent nursing facility care (99308) provided by the out of network provider on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 16, 2019 by an out of network provider, .You asked the Plan to pay forintensity-modulated radiation treatment (IMRT). You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring physician is also out-of-network with the Plan.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 forthe medical services provided on August 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on August 5, 2019.
You asked the Plan to pay for the lab services. You say that the services were necessary. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, the lab services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on August 5, 2019.