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

We decided that the Plan does not have to pay for the compression stockings identified with code A6531 that
were issued on January 31, 2020 to February 27, 2020.
You asked the Plan to pay for the compression stockings. You say that you were told to wear the stockings as a
part of your treatment. The Plan denied your request. The Plan says the compression stockings are not covered
for lymphedema.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that
compression bandages and gradient compression wraps are covered only when they are used as dressings over
a qualifying wound.
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you
do not have a medical condition for which compression stockings can be covered or paid for by Medicare.
Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code
A6531 that were issued on January 31, 2020 to February 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 Plasma-Based Comprehensive Genomic
Profiling testing provided on February 19, 2020 billed with multiple line items of different CPT codes.
You asked the Plan to pay for the Guardant 360 testing as billed. You say that this should not be denied as
experimental as this is a proven test which is supported for this patient. The Plan denied your request. The Plan
says on review, it was found that no payment can be made for this testing because the provider is unbundling
when there is a single CPT code which describes this testing.
The Plan must follow Medicare rules. Medicare rules say that in order to report the Guardant360 testing, one
unit of code 81479 should be reported with the appropriate DEX Z-code.
As there is a single CPT code which describes this testing, the rule for coverage of this testing as billed have
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 Plasma-Based
Comprehensive Genomic Profiling testing provided on February 19, 2020 billed with multiple line items of
different CPT codes.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections provided by a participating hospital on March 2, 2020.
You asked the Plan to waive the coinsurance for injections. You say that you were not paying this much in the past. You say that you think you are being over charged now. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for injections. The total allowed amount is $2,369.08. The total amount you are being asked to pay is $473.82 ($2,369.08 x 20% = $473.82). The correct coinsurance has been applied for the services that were provided. 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 for injections provided by a participating hospital on March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (CPT 84481 and CPT 86376) provided to 
the enrollee on January 8, 2020. 
 
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 the documentation submitted did not include a physician order/lab requisition or medical records 
stating exactly what tests are to be 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 the denied codes is: 
 
CPT 84481: 
 
Triiodothyronine T3; free 
 
CPT 86376: 
 
Microsomal antibodies (eg, thyroid or liver-kidney), each  
 
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 supported by the medical records. Our physician reviewer found no 
provider records have been submitted for review. Therefore, there is no evidence as to why the tests were being 
performed. The laboratory requisition notes that a thyroid panel and a free T4 were ordered. It is unclear what 
tests are included in the thyroid panel, but it seems odd that a free T4 would need to be ordered separately from 
the panel. The lab reports lists multiple tests under the heading of thyroid panel, including a free T4 and a 
thyroid antibody. As such, the documentation does not support that the provided services were medically 
necessary, reasonable, properly ordered or properly billed. 
 
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 laboratory services (CPT 84481 and CPT 86376) provided to the enrollee on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient services provided to the enrollee on January 9, 
2020. 
 
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 and the enrollee was 
referred by an out of network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 outpatient services provided to the enrollee on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural injection.
You asked the Plan to pre-approve the requested services. You say that you have been in pain since you had surgery. The Plan denied your request. The Plan says there is no significant imaging abnormality.
The Plan follows Medicare rules. Medicare rules say that lumbar epidural injections are only covered under certain medical 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 pre-approve the requested services. Our physician reviewer found that you have a diagnosis of chronic low back pain and lumbar radiculopathy involving the left leg. The documentation shows that pain medications are effective for 2 hours. You declined a referral for physical therapy. The most recent imaging studies do not reveal substantial abnormalities. The rules say that you need a failure of four weeks of non-surgical, non-injection care, which includes appropriate oral medications and physical therapy to the extent tolerated. Based upon the submitted documentation, the coverage rules have not been met. Therefore, the requested injection is not medically reasonable and necessary. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on October 20, 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 procedure code 32557 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 32557 is pleural drainage, percutaneous, with insertion of 
indwelling catheter; with imaging guidance. 
 
We find that CPT code 32557 is not supported in the medical record. Specifically, there is no documentation of 
a pleural drainage with insertion of indwelling catheter. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the surgical services rendered on October 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for wrist hand orthosis L3916 provided February 19, 2020. 
 
You asked the Plan to pay for the orthosis. You say that a thorough review of this documentation reveals that 
you dispensed medically necessary supplies pursuant to physician orders, which were received by the enrollee.  
The Plan denied your request. The Plan says the documentation submitted did not indicate the provider 
discussed the need for the billed supply code, therefore the billed supply code cannot be verified.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is noted to have multiple aches and pains in the setting of morbid obesity. No 
detailed history, recent injury or surgery, associated symptoms, review of systems or physical examination, 
including weakness and/or deformity, related specifically to wrist/hand pain or ankle/foot pain is documented. 
There is no evidence of diagnostic evaluation (i.e. x-rays) or prescription therapy provision/response (i.e. 
prescription meds, injections, PT/OT). Bilateral wrist/hand and bilateral ankle/foot orthoses were ordered, but 
only one wrist/hand orthosis was delivered. Therefore, the documentation does not support that the provided 
DME was medically necessity, reasonable or fulfilled as ordered. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for wrist hand orthosis L3916 provided February 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the post stabilization inpatient care provided to the enrollee
on December 1, 2019.
You asked the Plan to pay for the post stabilization inpatient care. You say that these services were medically
necessary. The Plan denied your request. The Plan says that pre-approval was not given prior to admission.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 post stabilization inpatient care. Our
reviewer says that that inpatient care was not medically reasonable and necessary for the enrollee in this case.
There was no documentation provided necessitating post-stabilization care services at the non-Plan facility on
12/1/19. The review has determined that the treating physician did not document (in the physician notes, on a
form, or in an order) that the patient was not stable for transfer on any dates of service. Our physician reviewer
found that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring
to a Plan facility for admission/observation level of care services after the emergency room evaluation on
12/1/19.
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 post stabilization inpatient care have not been met. Therefore, we decided
that the Plan does not have to pay for the post stabilization inpatient care provided to the enrollee on December
1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation and intraoral x-ray provided on April 28, 2020.
You asked the Plan to pay for the limited oral evaluation and intraoral x-ray. You say that this was an emergency. You say that they did not want to pull the tooth if the root canal could be redone. The Plan denied your request. The Plan says the services are not covered benefits.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation and intraoral x-ray provided on April 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 26, 2020 to January 28, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges due to the care received. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment per day for days 1-6 for inpatient hospital care. The enrollee has been asked to pay a $225 copayment for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 26, 2020 to January 28, 2020.
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: Inpatient Hospital
Decision: Favorable

We decided that the Plan does not have to pay for the acute inpatient hospital care rendered from March 3,
2020 to March 12, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan
denied your request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the services were medically necessary. Our physician reviewer found the enrollee presented to the
emergency department (ED) on March 3, 2020 with bilateral lower extremity cellulitis. He was started on
broad-spectrum anti-infective therapy. His hospitalization was prolonged secondary to non-compliance with
wound care. The records support that, at the time of the inpatient admission, the admitting physician reasonably
expected that the enrollee'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
does not have to pay for the acute inpatient hospital care rendered from March 3, 2020 to March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the lab services provided on March 16, 2020.
You asked the Plan to waive the copays for the lab services. The Plan denied your request. The Plan says the claims submitted for lab services processed 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 $10 copay for diagnostic lab services per day, per facility. The file shows that you received lab services from 2 different facilities. Your plan contract says that you pay a copay for lab services per facility. You have been asked to pay a $10 copay per facility for the lab services. The services fall within the outpatient diagnostic tests 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 copays for the lab services provided on March 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 17, 2019 by
an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent
nor urgent and prior authorization was not obtained to provide 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 laboratory services provided on September 17,
2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from March 13, 2020 to April 9, 2020.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you already received 13 chemotherapy treatments and disagree with the coinsurance for 3 dates of service. 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 20% coinsurance for Part B drugs. You received Medicare Part B drugs on March 13, 2020. The total allowed amount is $708.03 and 20% of that is $141.60. You received Medicare Part B drugs on March 27, 2020. The total allowed amount is $734.88 and 20% of that is $146.97. You received Medicare Part B drugs on April 9, 2020. The total allowed amount is $608.55 and 20% of that is $121.71. The total amount you owe is: $410.28. You have been asked to pay the total coinsurance amount of $410.28 for Medicare Part B drugs. Medicare Part B drugs fall within the Part B 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 for Medicare Part B drugs provided from March 13, 2020 to April 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on December 24, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. 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 physician's services provided on December 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on January 28, 2020.
You asked the Plan to waive the deductible for the office visit. You say that you have not received a reimbursement for this claim. 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 $150 combined deductible that applies towards in-network office visits. 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 $150 combined deductible that applies towards in-network office visits. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on January 28, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on January 28, 2020.