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

We decided that the Plan does not have to waive the copayment for the emergency services provided on July 31, 2020.
You asked the Plan to waive the copayment for the emergency care. You say that you were dissatisfied with the level of care provided at the previous emergency room visit on July 22, 2020. You say that if they had provided proper care at the first visit, a second visit to the emergency department would not have been necessary. The Plan denied your request. The Plan says Emergency services have been provided and require a $120 copayment. The Plan has also stated that they have opened a separate complaint regarding the quality-of-care concern.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 copayment for emergency care. You have been asked to pay a $120 copayment for the provided emergency 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 the emergency services provided on July 31, 2020.
Your complaint about the quality of care provided by a Plan-contracted provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute
setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Long term
acute care hospitals are certified as acute care hospitals, and in general, LTACHs do not provide clinical
services that are materially different than those of short-term acute care hospitals. The enrollee is receiving
acute hospital care, and acute care services have not been denied. The documentation does not support that the
enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is
currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare
criteria for LTACH services.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee.

You asked the Plan to pay for this transport. You say that this claim should be paid due to the destination exceptions provided due to COVID-19. The Plan denied your request. The Plan says Medicare coverage criteria for transport were not met. Maximus agreed with the Plans decision. You requested a reopen stating the destination exceptions, this claim should have been paid.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for ambulance transport. Maximus determined that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. The medical records show the enrollee is a 67-year-old man who was transported by ambulance to a physician's office for a follow-up dermatology appointment. It is noted that the enrollee was unable to ambulate due to left knee contractures. Vital signs were normal. The enrollee was transferred to the ambulance and then transported to the office. While CMS has temporarily expanded the list of allowable destinations for ambulance transports to include physician's offices, the general coverage rules for ambulance transport still apply. The documentation does not support that the another means of transport, such as a stretcher van, was contraindicated for the enrollee at the time of transport. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on the date of transport. The documentation does not support that the ambulance transport was medically reasonable and necessary for the enrollee in this case. There are not sufficient grounds for reversing the determination in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this transport have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services (A0428, A0425).

You asked the Plan to waive the copayment for the ambulance services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment has been 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 $240 copayment for Ambulance Transportation.

You have been asked to pay the Medicare allowable amount of $230.99 for the ambulance services. The allowable amount is less than the $240 noted in the plan contract. 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 ambulance services (A0428, A0425).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit.

You asked the Plan to waive the copayment for the urgent care visit. You say that COVID testing is covered in full. 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 $65 copayment per visit for Medicare-covered urgently needed services.

You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The records show the copayment applied to the urgent care visit and the COVID test was covered in full. 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 urgent care visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown (D2750) for tooth #30.

You asked the Plan to pay for the crown. You say that there is no reference to the service exceeding the frequency limitation in your benefit plan. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.

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, if a porcelain, porcelain fused to metal (PFM) or cast metal crown is less than five years old, even if unserviceable, its replacement is not a covered dental service. The record shows that you received a porcelain crown (D2750) on tooth #30 on January 8, 2016, and your crowns benefit for tooth #30 has been exhausted. Therefore, we decided that the Plan does not have to pay for the porcelain crown (D2750) for tooth #30.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that this is needed for monitoring. The Plan denied your request. The Plan says that there are no skilled needs.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that the requested admission is medically reasonable and necessary. Our physician reviewer found although you do not have documented skilled nursing needs, you do have documented skilled therapy needs. You are not shown to have reached a plateau in function. Daily skilled services are required to establish a maintenance program or to prevent deterioration of your condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).

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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency services provided on November 11, 2020.
You asked the Plan to waive the copayment for the emergency services. You say that you were dissatisfied with the care provided. The Plan denied your request. The Plan says emergency care was provided, which requires a $50 copayment.
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 $50 copayment for emergency care. You have been asked to pay a $50 copayment for emergency services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency services provided on November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the vision exam you had on October 14, 2020.
You asked the Plan to waive the copayment. You say that you were told there would be no cost for this. The Plan denied your request. The Plan says you are responsible for the copayment.
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 $10 copayment for outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye. Review of the file shows that you had a vision exam on October 14, 2020. You have been asked to pay a $10 copayment for the exam. The exam falls within the vision 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 the vision exam you had on October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth number 4 and core build up (D2950) for tooth numbers 3 and 14.

You asked the Plan to these dental services. You say that these services are medically necessary. The Plan denied your request. The Plan says the crown benefit is not currently available and core build up is not covered under the dental benefit at all. Maximus agreed with the Plan regarding the core build up but indicated the Plan had approved the crown. The Plan requested a reopen and stated that Maximus did not interpret the case correctly.

The Plan is correct in this case. 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. The Plan contract says that crowns are covered every 60 months. The records show the Plan paid for a crown in 2019, therefore that service is not currently available. The Plan contract also states that core build up is not a covered benefit. Therefore, we have now decided that the Plan does not have to pre-approve a crown (D2740) for tooth number 14 and core build up (D2950) for tooth numbers 3 and 14.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 7, 2020, to August 26, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no nursing services which would be considered skilled services by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 7, 2020, to August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse a greater amount for the acupuncture services (97813) provided from August 22, 2020 to October 22, 2020.
You asked the Plan to reimburse a greater amount for the acupuncture services. You say that you saw that the Plan would cover 50% of the cost for acupuncture services. When you requested reimbursement, the Plan did not give you half of what you paid. The Plan denied your request. The Plan says that the contract states that the Plan will pay 50% of the allowed cost or 50% of the acupuncturist's charges, whichever is less. In this case, the Plan's allowed cost was less than the acupuncturist charged. You received these services from an out-of-network provider, which leaves you responsible for the remainder of the cost.
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 50% coinsurance for acupuncture. You were reimbursed $20.41 for each of 10 sessions of acupuncture, for a total of $204.10. The provider charged $60, but the Plan's allowed amount for these services was $40.82 per session. Because the Plan's allowed amount was less than the provider's charges, you were reimbursed 50% of the Plan's allowed amount for the 10 covered sessions. This provider was out of network, which also leaves you responsible for the remainder of the acupuncturists charge. This means that you have been reimbursed 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 reimburse a greater amount for the acupuncture services (97813) provided from August 22, 2020 to October 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member can remain in the current acute care location until such time no further acute level care is needed.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The short-term acute care hospital can provide for all of the patient's present inpatient care needs and the patient is receiving an appropriate level of care in the present setting. Continued care in the short-term acute care hospital is appropriate until the patient is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of a portable x-ray (R0075) provided on October 12, 2020.
You asked the Plan to pay for the transportation of a portable x-ray. You say that you would like reconsideration because these services were medically necessary. The Plan denied your request. The Plan says as CPT code R0075 is a technical component only code, it should be reported on a hospital setting.
The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A SNF stay, the transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation of a portable x-ray have not been met. Specifically, the claim was billed with place of service code 31 indicating that the member was in a Part A Skilled Nursing Facility stay. This service is subject to consolidated billing and not separately billable to Medicare Part B. Therefore, we decided that the Plan does not have to pay for the transportation of a portable x-ray (R0075) provided on October 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an external defibrillator (K0606).

You asked the Plan to waive the coinsurance for an external defibrillator. You say that the item should be covered. The Plan denied your request. The Plan says the cost share 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 20% coinsurance for durable medical equipment and related supplies.

You have been asked to pay a 20% coinsurance for an external defibrillator. This item falls within the durable medical equipment and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an external defibrillator (K0606).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 25, 2020, to August 27, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says that based on the records this might be an observation stay.
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 review has determined that the record showed 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 for the acute inpatient hospital care provided from August 25, 2020, to August 27, 2020.