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

We decided that the Plan does not have to waive the copayment for outpatient surgery services provided on August 27, 2019.You asked the Plan to waive the copayment for outpatient surgery. You say that you only went to this provider for a consultation and did not expect this surgery, and this procedure was done in a doctor's office not in a hospital.The Plan denied your request. The Plan says the copayment 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 $400 copayment for outpatient surgery at an outpatient hospital facility. The provider is considered to be an outpatient hospital facility, therefore the outpatient hospital surgery copayment applies to this claim.You have been asked to pay $400 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery services provided on August 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures services coded 77003 provided to the enrollee on August 8, 2019.You asked the Plan to pay fo rthe fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were not billed with an appropriate primary code.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 77003 is Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure).We find that CPT code 77003 is not supported in the medical record. Specifically, this code was not billed with an appropriate primary code. Based on this information, we decided that Medicare rules for coverage of the fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures services have not been met.Therefore, we decided that the Plan does not have to pay for the fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures services coded 77003 provided to the enrollee on August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic testing supplies provided to the enrollee from July 25,2019 to October 13, 2019.You asked the Plan to pay for the diabetic testing supplies. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the delivery ticket submitted is missing required information.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 physician order and 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. Review of the file shows that the submitted delivery ticket did not include the carrier's tracking number. The proof of delivery did not include an order number or details to validate the delivery ticket submitted. Therefore, we decided that the Plan does not have to pay for the diabetic testing supplies provided to the enrollee from July 25, 2019 to October 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial observation care services provided to the enrollee on July 13, 2019.
You asked the Plan to pay for the initial observation care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee was enrolled in hospice until the first day of the month following the month in which hospice was revoked.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on July 13, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial observation care services provided to the enrollee on July 13, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport services provided to the enrollee on August 17, 2019 and billed under codeA4670.You asked the Plan to pay for this transport. You say that this claim should be paid.The Plan denied your request. The Plan says while a portion of this claim was paid, code A4670 has a status code of "N" is not paid per Medicare guidelines.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 A4670 cannot be paid as billed due to its Medicare payment status. Therefore, we decided that the Plan does not have to pay for ambulance transport services provided to the enrollee on August 17, 2019 and billed under codes A0427, A0425, A0422, A0382 and A4670.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee from April 30, 2019 to May 9, 2019.You asked the Plan to pay forthis 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 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 to the enrollee from April 30, 2019 to May 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe diabetic testing supplies provided from August 3, 2019 to October 22, 2019.You asked the Planto pay forthe diabetic testing supplies. You say that the documentation supports that payment should be made.The Plandenied your request. The Plansaysthe proof of delivery documentation is not sufficient to support that payment is warranted.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 is not signed and does not include the tracking number. Similarly, the delivery confirmation is for a later date than the billed date of service and has no identifying information to support that it is confirmation for the items at issue.Therefore, we decided that the Plandoes not haveto pay forthe diabetic testing supplies provided from August 3, 2019 to October 22, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

e decided that the Plan does not have to pay for physician services provided to the enrollee from August 7, 2019 to August 8, 2019 and billed under code 99498-GC.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 that Medicare guidance says an add-on code is a HCPCS/CPT code that describes a service that is always performed in conjunction with another primary service. An add-on code with one exception is never eligible for payment if it is the only procedure reported by a practitioner. The Plan says CPT code 99498-GC was billed as a primary code that is not eligible for payment to the same practitioner for the same patient on the same date of service. 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, code 994498-GC has created an error preventing payment. The Plan states a corrected claim would be accepted if submitted. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee from August 7, 2019 to August 8, 2019 and billed under code 99498-GC
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220), and the surgical extraction (D7210) provided on May 11, 2019.You asked the Plan to pay for the x-ray, and surgical extraction. You say that you needed an emergency extraction.The Plan denied your request. The Plan says periapical x-rays are not listed as a covered service. The Plan says that extractions are not listed as a covered service either.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 periapical x-ray, and extraction are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0220), and the surgical extraction (D7210) provided on May 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on September 18, 2019 by an out of network provider. You asked the Plan to pay for the chiropractic services. You say that you were out of town and this was the only doctor that could provide services.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered. 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 the chiropractic services provided on September 18, 2019 by an out of network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital discharge day management; more than 30 minutes (99239) provided on January 31, 2019 by "the provider". You asked the Plan to pay forhospital discharge day management; more than 30 minutes. You say that the services were provided and payment should be rendered.The Plan denied your request. The Plan says based on Medicare billing criteria, Medicare fee-for-service retains payment responsibility for all hospice and non-hospice related claims beginning on the date of the hospice election.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 forhospital discharge day management; more than 30 minutes (99239) provided on January 31, 2019 by "the provider".
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on August 21, 2019.You asked the Plan to waive the copayment for an ER visit. You say that you were discharged too soon and 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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for an ER visit. An ER visit falls within the emergency care 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 ER visit provided on August 21, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora portable oxygen concentrator (E1392) provided on April 30, 2019 by "the provider"l.You asked the Plan to pay forthe portable oxygen concentrator. You say that the lightweight concentrator is necessary in improving your quality of life since you are no longer able to move the heavier oxygen tanks.The Plan denied your request. The Plan says the item was purchased. Therefore, coverage criteria has not been met.The Plan must follow Medicarerules. Medicare rules say that Medicare does not pay for oxygen equipment that is purchased on or after June 1, 1989. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the portable oxygenconcentrator have not been met.Therefore, we decided that the Plan does not have to pay fora portable oxygen concentrator (E1392) provided on April 30, 2019 by "the provider".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the annual visit provided on June 27, 2019.You asked the Plan to waive the coinsurance for the annual wellness visit. You say that there is a $0 copayment for your annual wellness visit.You say that the Plan should stay with what they advertise. The Plan denied your request. The Plan says the coinsurance 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 40% coinsurance for the annual wellness visit from an out-of-network provider.You have been asked to pay $63.78, which is 40% of the allowed amount for the annual wellness visit. The allowed amount is $159.46 (40% x $159.46 = $63.78). The annual wellness visit falls within the "Annual Wellness Visit" benefit category. The records show that the provider is out-of-network. 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 annual visit provided on June 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided as a result of telehealth services provided to the enrollee on July 17, 2019 and billed under code 81450. You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says these services were ordered as a result to conversations during a telehealth visit. The records provided do not show the required coverage criteria were met either for the service itself or for telehealth 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) located in 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 an in-person encounter. Consequently, the items or services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for lab services provided as a result of telehealth services provided to the enrollee on July 17, 2019 and billed under code 81450.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for more than 30 minutes of discharge day management services (99239) provided on September 5, 2019.You asked the Plan to pay for the discharge day management services. You say that you would like reconsideration as the services were performed in good faith. The Plan denied your request. The Plan says the submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed.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 99239 is hospital discharge day management; more than 30 minutes. 
We find that CPT code 99239 is not supported in the record. Specifically, the record does not indicate that more than 30 minutes of hospital discharge day management services were rendered. Based on this information, we decided thatMedicare rules for coverage of the discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for more than 30 minutes of discharge day management services (99239) provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided to the enrollee on July 5, 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 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 the physician services provided to the enrollee on July 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on May 24, 2019 and billed under code G0483.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 records provided do not support the services billed.The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay fordrug testing provided to the enrollee on May 24, 2019 and billed under code G0483.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lesion removal provided on May 6, 2019.You asked the Plan to waive the copayment for lesion removal. You say that you do not understand why you are liable. You say that you are appealing the non-payment from the Plan.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 a $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.You have been asked to pay $152, which is less than the standard $295 copayment for lesion removal. Lesion removal falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. Lesion removal is considered a surgical procedure. 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 lesion removal provided on May 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided to the enrollee on January 29, 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 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 the vision services provided to the enrollee on January 29, 2019.