Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forsubsequent nursing facility care (99309) provided on August 18, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe nursing facility care. You say that your physician provided medically necessary services to the enrollee in good faith. In consideration for the services rendered, your doctor is seeking reimbursement.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 forsubsequent nursing facility care (99309) provided on August 18, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three periodontal scalings and root planings provided.

You asked the Plan to pay for the scalings and planings. You say that you believe the enrollee's periodontal disease should be covered as part of the Plan.

The Plan denied your request. The Plan says this service is not a benefit under the dental 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe three periodontal scalings and root planings provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadditional power wheelchair accessories (K0108 and E2300).You asked the Planto pre-approvethe accessories. You say that  The Plandenied your request. The PlansaysThe Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose, and it must be needed for use in the home.The power seatelevation system (E2300) is not primarily medical in purpose. The transit system (K0108) does not serve a purpose in the home.Therefore, we decided that the Plandoes not haveto pre-approveadditional power wheelchair accessories (K0108 and E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lithium batteries (Q0506) provided on May 15, 2020.You asked the Plan to pay forthe lithium batteries. You say that you would like reconsideration because these supplies are medically necessary.The Plan denied your request. The Plan says the documentation does not include an itemized billing/shipping invoice to verify the billed supplies.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. The documentationdoes not include an itemized billing/shipping invoice to verify the supplies that have been billed. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forthe lithium batteries (Q0506) provided on May 15, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 5, 2020 by an out of network (OON) provider.You asked the Plan to pay forelectrocardiogram. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 providersonly 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 had network providers available who could have provided 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 forthe medical services provided on June 5, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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. Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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-approvelong-term acute care hospital (LTACH) services
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ultrasound scan of veins of one arm or leg (93971) provided on June11, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe ultrasound scan of veins of one arm or leg. You say that the service provided was medically necessary.The Plan denied your request. The Plan says there was no prior authorization for the services rendered by the OON 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 forthe ultrasound scan of veins of one arm or leg (93971) provided on June 11, 2020 by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B medication provided on
September 28, 2020.
You asked the Plan to waive the coinsurance for the Part B medication. You say that this injection costs a lot of
money. You say this service should be totally covered. 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 20%
coinsurance for Medicare Part B prescription drugs.
You have been asked to pay $238.80 which is 20% of the allowed amount for the Part B medication. The
allowed amount is $1,194. ($1,194 x 20% = $238.80). The Part B medication falls 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 the Part B
medication provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Part B medication provided on July 15, 2020.You asked the Plan to waive the coinsurance forthe Part B medication. You say that you owe $0 and that you are being overcharged. 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 20% coinsurance for all other in-network drugs covered under Medicare Part B. You have been asked to pay $467.57 which is 20% of the allowed amount for the Part B medication. The allowed amount is $2,337.22. ($2,337.22 x 20% = $467.57). The Part B medication falls 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 forthe Part B medication provided on July 15, 202
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on May 5, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says the testing is not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 23, 2020, by an out-of-network provider.You asked the Plan to pay forthe medical services. You say that the claim should be paid.The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider and the services were not urgent or emergent, nor were they approved in advance.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 had network providers available who could have provided 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 forthe medical services provided on October 23, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) provided on January 31,
2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that due to the health conditions of the enrollee required
your doctor to do the procedure. Due to this you were unable to take a prior authorization for the services
billed. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted
providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided 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 outpatient office visit (99214) provided on
January 31, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe endodontic therapy (D3330) provided on June 2, 2020.You asked the Plan to pay forthe endodontic therapy. You say that you would like to appeal this service.The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe endodontic therapy (D3330) provided on June 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forselective catheter placement (CPT 36011) services provided to the enrollee on June 26, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says procedure code 36011-59 is not supported in the medical records submitted.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 36011 is "selective catheter placement into a first order branch venous system (renal vein, jugular vein)."We asked our coding 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 coding reviewer found the operative report did not document that selective catheter placement into first order branch was performed, and therefore this service cannot be verified.We looked at this coder'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 forselective catheter placement (CPT 36011) services provided to the enrollee on June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe retainer (D6545) provided on September 11, 2020.You asked the Plan to reimburse you forthe dental item. You say that you do not agree with the decision.The Plan denied your request. The Plan says the retainer is not listed as a covered dental item.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.Additionally, the dental itemyou are asking the Plan to reimburse you forinvolve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you forthe retainer (D6545) provided on September 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for an ultrasound (76642) provided.

You asked the Plan to waive the co payment for an ultrasound. You say that you believe you are being overcharged.The Plan denied your request. The Plan says this processed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 co payment for diagnostic procedures and tests provided in a specialist office, urgent care, or hospital. 

You have been asked to pay a $25 co payment for an ultrasound, which is a diagnostic procedure. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the co payment for an ultrasound (76642) provided.
Appeal type: Imaging
Decision: Favorable


We decided that the Plan does not have to waive or reduce $150 copayment charged for a magnetic resonance imaging (MRI) provided on May 13, 2020.

You asked the Plan to waive or reduce this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the service provided and the Plan contract agreement. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan confirmed the provider was in network and the claim submitted met  the level of diagnostic imaging that warrants the $150 copayment per the Plan contract.

The Plan is correct in this case. 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 could be charged a $150 copayment for outpatient imaging. 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 or reduce $150 copayment charged for a magnetic resonance imaging (MRI) provided on May 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a hip fracture after a fall. Your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical recorddocuments a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional mileage received during an ambulance
transport on August 24, 2020.
You asked the Plan to pay for the additional mileage received during an ambulance transport. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services
received are not a covered benefit.
Medicare pays for ambulance services to the nearest appropriate facility. The Plan follows the same rules.
We looked at the file and Medicare rules. Review of the file shows that you received ambulance services on
August 24, 2020. Per your request, you were transported to a hospital that was not the nearest available
hospital. Based on this information, we decided that Medicare rules for coverage of the additional mileage
received during an ambulance transport have not been met. This means that you are responsible for the
difference in mileage from the nearest hospital to the requested hospital. Therefore, we decided that the Plan
does not have to pay for the additional mileage received during an ambulance transport on August 24, 2020.
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 medical services. You say that the claim should be paid. The Plan denied
your request. The Plan says Medicare denies a claim if it is not received by the plan within twelve months or
one calendar year from the date when the services were rendered.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the medical services was not filed until September 24, 2020. This means that
more than one calendar year from the date of service had passed before a claim was filed. Therefore, 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.