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

We decided that the Plan does not have to pre-approve a U Step 2 heavy duty, multiple breaking system, variable wheel resistance walker.
You asked the Plan to pre-approve a U Step 2 heavy duty, multiple breaking system, variable wheel resistance walker. You say that the item is necessary for the enrollee's medical condition. The Plan denied your request. The Plan says U Step 2 is not a covered brand. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a U Step 2 heavy duty, multiple breaking system, variable wheel resistance walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a U Step 2 heavy duty, multiple breaking system, variable wheel resistance walker.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 6, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.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 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 for the medical services provided to the enrollee by an out-of-network provider on November 6, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyewear providedon December 6, 2019.You asked the Plan to reimburse you for the eyewear. You say that you should have a balance of $77.95 toward the eyewear benefit for 2019. The Plan denied your request. The Plan says you have received the maximum $250 eyewear reimbursement.Medicare generally does not cover routineeyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows the eyewear benefit was used on September 26, 2019 with a reimbursement of $89.44 and October 9, 2019 with a reimbursement of $160.56, which totals a maximum $250 reimbursement. Therefore, we decided that the Plan does not have to reimburse you for eyewear provided on December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on October 28, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for chiropractic services. You say that you were told that authorization was not
required. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that
there are in-network providers available.
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 chiropractic services provided on October 28,
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 2, 2019 to December 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that these services were medically necessary. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says these services could have been 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 an office visit provided on October 2, 2019 to December 11, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sildenafil Tab 20mg.You asked the Plan to pre-approve Sildenafil Tab 20mg. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveSildenafil Tab 20mg.Benefits for Sildenafil Tab 20mgmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning anybenefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered to you on
November 5, 2019.
You asked the Plan to waive the copayment for these services. You say that you believed the visit was for
preventive services. The Plan denied your request. The Plan says the copayment 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 $40
copayment for in-network specialist services.
Review of the file shows that you received specialist services on November 5, 2019. You did not receive any
services that are considered preventive by Medicare or the Plan that have no copayment. You have been asked
to pay a $40 copayment for these services. These services fall within the in-network specialist 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 the specialist services rendered to you on
November 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99202) and spinal x-ray (72100) provided on November 11, 2019.You asked the Plan to pay for the office visit and x-ray. You say that you would like reconsideration because you were in pain and these services were necessary to prevent a trip to the emergency room.The Plan denied your request. The Plan says there is not a coverage benefit for procedures which are not spinal manipulation to correct spinal subluxation.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for an office visit (99202) and spinal x-ray (72100) provided on November 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift chair.
You asked the Plan to pre-approve a seat lift mechanism of a seat lift chair. You say that because of an accident
you are in pain and have balance issues. The Plan denied your request. The Plan says you are independent with
sitting and standing and you do not have the condition that is needed to be approved for a power seat lift chair.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions
listed above are met. Medicare does not cover the upholstered portion of a seat lift chair.
We looked at the file and Medicare rules. The physical therapy evaluation shows you are able to sit and stand
from your sofa and the records do not show you have severe arthritis of the hip or knee or have a severe
neuromuscular disease. Based on this information, we decided that Medicare rules for coverage of a seat lift
chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound examination provided on October 28, 2019.
You asked the Plan to waive the copayment for ultrasound. You say that you were told this would be a $35 copayment. 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 $95 copayment for in-network ultrasound at an outpatient hospital. You have been asked to pay $95 copayment for ultrasound. Ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound examination provided on October 28, 2019.
Your complaint regarding receiving inaccurate information about the cost-share for this service 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on October 2, 2018.You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this service is considered a bundled procedure as the cost is included in the cost of the primary procedure.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 CPT code 95999 is not supported in the record. Specifically, train of four monitoring is considered integral to the approved primary procedure. Payment for this service is bundled in the cost of the primary procedure. Based on this information, we decided that Medicare rules for coverage of the train off our monitoring have not been met.Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on October 2, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a sleep study (95806) provided on March 27, 2019.
You asked the Plan to pay for a sleep study. You say that this is supported by the medical records. The Plan denied your request. The Plan says this code is not supported by the submitted documentation.
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 95806 is sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement). 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 a sleep study. Our reviewer says that this CPT code is not supported by the medical records. Our physician reviewer found the medical records do not include documentation of recording of respiratory airflow, and respiratory effort (eg, thoracoabdominal movement). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a sleep study have not been met. Therefore, we decided that the Plan does not have to pay for a sleep study (95806) provided on March 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on September 20, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no valid authorization for these services.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 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 medical services provided to you by an out-of-network provider on September 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 2, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available 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 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 for the medical services provided to the enrollee by an out-of-network provider on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99153) provided on July 20,
2019.
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration
because the services rendered were medically necessary. The Plan denied your request. The Plan says payment
for this service is included in payment to the facility and not separately reimbursable for this provider in this
place of service.
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the moderate sedation services have not been met. Specifically, payment for this service is the
responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for
moderate sedation services (99153) provided on July 20, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for initial hospital care (99222) and subsequent hospital care (99232) provided on July 28, 2019 through October 20, 2019.
You asked the Plan to pay for the hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the charges for these services are included in another procedure code.
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 forwarded sufficient information to show that either of these codes were billed with a bundled code and are not separately payable. Therefore, we decided that the Plan has to pay for initial hospital care (99222) and subsequent hospital care (99232) provided on July 28, 2019 through October 20, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a heart/lung machine provided on October 21, 2019.
You asked the Plan to pay for the heart-lung machine set up and operation. You say that this is a medically necessary service and should be reimbursed by the plan. The Plan denied your request. The Plan says this is a service that is included in payment to the hospital for the inpatient stay.
The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. Although these services may be appropriate, payment for them is made to the hospital which must then furnish these services either directly or under arrangements. As such, separate Medicare payment cannot be made for the services at issue. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a heart/lung machine provided on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit provided on December 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a home visit. 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.
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 a home visit provided on December 11, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveComputed Tomography (CT) Angiogram of the Neck (70498).You asked the Plan to pre-approvethe CT scan. You say that the CT scan is medically necessary.The Plan denied your request. The Plan says rules for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pre-approve the CT scan. Our reviewer says that the CT scan is not medically necessary. Our physician reviewer found physical examination notes no neurologic deficits or audible carotid bruits. As such, the requested CTA of the neck is not shown to be currently medically necessary or reasonable.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approveComputed Tomography (CT) Angiogram of the Neck (70498).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you didn't know enough to choose the right plan and you couldn't reach your regular insurance agent The Plan denied your request. The Plan says no prior authorization was obtained.
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 an office visit provided on December 3, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spinal injection provided on November 6, 2019.
You asked the Plan to waive the copayment for the spinal injection. You say that you do not feel you should owe the copayment because the authorization was approved. 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 $180 copayment for surgery services at an in-network ambulatory surgical center. You have been asked to pay a $180 copayment for the spinal injection. The spinal injection 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 the spinal injection provided on November 6, 2019.