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

We decided that the Plan does not have to pay for a skin biopsy provided on April 2, 2019. You asked the Plan to pay for skin biopsy. You say that this doctor is not a hospice provider. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the enrollee was enrolled in a hospice program on this date of service and therefore the Plan is not responsible for payment. 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 for a skin biopsy provided on April 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for definitive drug testing (G0483) provided to the enrollee on April 8, 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 records provided and the physician order do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare also has specific documentation requirements for this type of testing. Based on the records provided, Medicare coverage criteria were not met. Therefore, we decided that the Plan does not have to pay for definitive drug testing (G0483) provided to the enrollee on April 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroffice services, X-Ray examination, and injection provided by "the provider",  on July 11, 2019.Youasked the Plan to pay foroffice services, X-Ray, and injection. You say that these services were unrelated to hospice care.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the enrollee was enrolled in a hospice program on this date of service and therefore the Plan is not responsible for payment.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays forclaims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. L. Cole 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 foroffice services, X-Ray examination, and injection provided by "the provider" on July 11, 2019
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for inpatient services provided to the enrollee on July 3, 2019 and billed under code 99239.
You asked the Plan to pay for code 99239. You say that this claim should be paid. The Plan denied your request. The Plan says that based n the medical records provided the submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed A documented duration of time of 3l minutes or more is required to support this code. Therefore, the billed service cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code and when necessary those codes must be specifically supported by time duration in the medical records.
When MAXIMUS receives an appeal an acknowledgement letter is sent to all parties giving them an opportunity to submit additional information. Your office submitted additional medical record information that shows a total of 40 minutes was spent with the enrollee for discharge purposes therefore meeting the criteria for the billing of code 99239. Based on this information, we decided that Medicare rules for coverage of code 99239 have been met. Therefore, we decided that the Plan has to pay for inpatient services provided to the enrollee on July 3, 2019 and billed under code 99239.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for codes 97110 and 97530 for dates of service December 06, 2018 through January 03, 2019.
You asked the plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says while a portion of this claim was paid, codes 97110 and 97530 for dates of service December 06, 2018 through January 03, 2019 are not supported by the Medical records provided.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules state that the records provided must support the services billed. In this case, the records provided do not support the payment of codes 97110 and 97530 for dates of service December 06, 2018 through January 03, 2019. Medicare billing criteria are not met. Therefore, the Plan is not required to pay for codes 97110 and 97530 for dates of service December 06, 2018 through January 03, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the advance care planning services coded 99498 provided to the enrollee on April 18, 2019.
You asked the Plan to pay for the advance care planning services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 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 99498 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; each additional 30 minutes (List separately in addition to code for primary procedure). We find that CPT code 99498 is not supported in the medical record. Specifically, the submitted medical records do not include sufficient information to support the performance of advance care planning, each additional 30 minutes. A documented time of 31 minutes is in sufficient to support the additional charge. Based on this information, we decided that Medicare rules for coverage of the advance care planning services have not been met. Therefore, we decided that the Plan does not have to pay for the advance care planning services coded 99498 provided to the enrollee on April 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit, blood draw, and laboratory testing provided by out of network provider.
You asked the Plan to pay for the laboratory services. You say that the services were provided to the enrollee in good faith. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says the services were not urgent or emergent in nature.
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 rendering facility is not a network provider either. 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 hospital outpatient clinic visit, blood draw, and laboratory testing provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on May 17, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says plasmapheresis/apheresis is not covered by Medicare for the diagnoses on the claim.The Plan must follow Medicare rules. Medicare rules say that apheresis is covered only for specific indications.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 services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found plasmapheresis/apheresis is not covered by Medicare for the diagnoses on the claim. The review has determined that the enrollee does not have one of the covered indications for this service. The service provided 
on May 17, 2019 was not medically necessary and 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 services have not been met.Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided on May 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forinjections of hyaluronan provided bythe provider from May 7, 2019 to May 21, 2019.You asked the Plan to waive the coinsurance forinjections. You say that the last time Orthovisc was used on you it did not work, and you were never told that there would be any charged that you would be held responsible for.The Plan denied your request. The Plan says the coinsurance amounts you are being charged are 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 20% coinsurance for Part B drug injections. The allowed amount of these injection is $1,424, however you have only been asked to pay $262.02 which is less than 20% coinsurance for injections.You have been asked to pay $262.02, which is less than 20% coinsurance for injections. Injections fall within the Medicare Part B Prescription Drugs 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 forinjections of hyaluronan provided from May 7, 2019 to May 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit, and comprehensive assessment of and care planning provided on July 30, 2019 by the out of network provider.
You asked the Plan to pay for the practitioner services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says that the services were not urgent or emergent in nature.
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 rendering facility is not a network provider either. 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 rest home visit, and comprehensive assessment of and care planning provided on July 30, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided.
You asked the Plan to waive the copayment for urgently needed services. You say that you had a primary care provider visit, not urgent care services. 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 $55 copayment for urgently needed services. The medical record shows that you received urgently needed services to treat a sinus infection. Therefore, you are responsible to pay the $55 copayment. You have been asked to pay a $55 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 urgently needed services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 21, 2019 by an out of network provider. 
You asked the Plan to pay for the office visit. You say that the services provided were medically necessary. The Plan denied your request. The Plan says this provider billed with an NPI that is not in-network with the member's 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 a network provider with the Plan, but billed with an NPI that is out-of-network. 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 medical services provided on May 21, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing rendered to the enrollee on August 9, 2019.
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 the testing is not covered.
The Plan must follow Medicare rules. The rules say that biomarkers (specifically, EPI, MiPS, and SelectMDx) are deemed investigational. The testing at issue is the ExoDx Prostate Intelliscore (EPI) test. This test is considered to be investigational by Medicare and is therefore not covered. Therefore, we decided that the Plan does not have to pay for the testing rendered to the enrollee on August 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ankle foot orthoses provided by the provider on April 3, 2019.You asked the Plan to pay forthe ankle foot orthoses. You say that The Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.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 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. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe ankle foot orthoses provided on April 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (CPT 99214) provided to the enrollee on July 27, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says services that are considered column II procedures to another service are not eligible for reimbursement when billed with the column I procedure 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. We find that CPT code 99214 is not supported in the medical record. Specifically, this code is a column II procedure to the column I procedure already billed on this claim - CPT 99220. This code cannot be billed separately. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (CPT 99214) provided to the enrollee on July 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for partial dentures (D5213 and D5214) provided on September 11, 2019.
You asked the Plan to pay for the partial dentures. You say that you would like reconsideration as you had to have your partials remade due to another procedure. The Plan denied your request. The Plan says the services are covered benefits, but you have exceeded the limits set in your subscriber agreement.
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 covers the partial dentures when the services are medically necessary and reasonable. We looked at your request, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the partial dentures have not been met. The record indicates that you have exceeded your annual maximum of $2,500 for 2019. Therefore, we decided that the Plan does not have to pay for partial dentures (D5213 and D5214) provided on September 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transport provided by Ambulance on July 30, 2019.
You asked the Plan to pay for the ambulance services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee was an inpatient at the time of transport.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the transport provided by Ambulance on July 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that The Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
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 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. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive thecopayment for the physician services rendered to you on September 14, 2018.You asked the Plan to waive the copayment for these services. You say that you didn't choose to be examined by this doctor.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 $15 copayment for each covered visit or consultation in an outpatient location with a specialist. Review of the file shows that you received physician services in an outpatient location on September 14, 2018. You have been asked to pay a $15 copayment for these services. These services fall within the covered visit or consultation in an outpatient location with a specialist 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 physician services rendered to you on September 14, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on August 6, 2019.You asked the Plan to waive the deductible for the office visit. You say that you have never been charged this much for an office visit before. You say you would like the claim reprocessed. 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. Your contract with the Plan says that there is a $1,000 deductible that applies towards provider and professional services at an out-of-network primary care physician's office. The office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that applies towards provider and professional services at an out-of-network primary care physician's office. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on August 6, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on August 6, 2019.