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

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on January 6, 2021 and January 13, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that you did not pay your copayments at the time of service. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for services received from an in-network Level 1 specialist physician at an independent office. 

You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit provided on January 6, 2021 and January 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy visits provided from August 28, 2020, to September 11, 2020.You asked the Plan to waive the copayments for physical therapy visits. You say that you were not notified that there was a limit to the in-network approval for these services.The Plan denied your request. The Plan says the copayment 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 $25 copayment for each out-of-network physical therapy visit. There were 5 visits, resulting in a total copayment obligation of $125.
You have been asked to pay $25 copayment for each physical therapy visit. Physical therapy visits fall within the Outpatient Rehabilitation 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 copayments for physical therapy visits provided from August 28, 2020, to September 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on July 27, 2020.

You asked the Plan to pay for code 97110. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 97110 provided on July 27, 2020.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that the therapy services were performed. No medical records for the date of service in dispute were provided for review. Therefore, we decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on July 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown -full cast high noble metal (D2790) for tooth 3, pontic -porcelain fused to high noble metal (D6240)for tooth 5, and pontic -resin with high noble metal (D6250) for tooth 6 and tooth 4.You asked the Plan to pre-approve a high gold content crown for tooth 3, a false tooth for bridge for tooth 5 and white glass with high gold content caps for bridge for tooth 6 and tooth 4. You say that you would like the services covered.The Plan denied your request. The Plan says these services are not covered under your dental 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 pre-approve a crown -full cast high noble metal (D2790) for tooth 3, pontic -porcelain fused to high noble metal (D6240) for tooth 5, and pontic-resin with high noble metal (D6250) for tooth 6 and tooth 4.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 12, 2021, by an 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 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 laboratory services provided on February 12, 2021, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you need strengthening, mobility, and wound care. The Plan denied your request. The Plan says you do not need an intensive therapy program to improve self-care functioning and walking.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 physician reviewer found that you were admitted to the acute hospital for right leg cellulitis and was discharged home with home health services. There are ongoing issues with mobility and ability to perform activities of daily living. Your medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.

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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc-One shoulder injection.
You asked the Plan to pre-approve a Synvisc-One shoulder injection. You say that you are still having stiffness and need pain relief. The Plan denied your request. The Plan says you have already had a repeat injection.
The Plan must follow Medicare rules. Medicare rules say that repeat injections of Synvisc-One for shoulder arthritis are limited to a single repeat course. We looked at the file and Medicare rules. The record shows that you have previously had a repeat course of Synvisc-One. Based on this information, we decided that Medicare rules for coverage of a Synvisc-One shoulder injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Synvisc-One shoulder injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the unlisted special service purchased on August 26, 2020.
You asked the Plan to reimburse you for the unlisted special service. You say that the cane should be covered. The Plan denied your request. The Plan says the unlisted special service charge is not reimbursable.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the unlisted special service have not been met. Delivery and service fees are not covered by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the unlisted special service purchased on August 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from December 17, 2020 to December 25, 2020.You asked the Plan to waive the copayment for the inpatient hospital services. You say that you feel the enrollee should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says the enrollee had inpatient hospital care on the dates of service at issue in this appeal. The Plan says that the correct copayment has applied per the enrollee's contract with the Plan.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 $325 copayment per day for days 1-6 for Inpatient hospital care. 
We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received inpatient hospital services from December 17, 2020 to December 25, 2020. The enrollee has been asked to pay a $325 copayment per day for days 1-6 for the inpatient hospital services, totaling $1950. The inpatient hospital services fall 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 the inpatient hospital services provided from December 17, 2020 to December 25, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97530 provided on March 25, 2020.

You asked the Plan to pay for code 97530. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 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.

We find that CPT code 97530 is not supported in the medical record. Specifically, the records indicate that the services were performed by an occupational therapy assistant in a home health or hospice setting. There is a more appropriate code for the services provided in a home health setting. Based on this information, we decided that Medicare rules for coverage of code 97530 have not been met. Therefore, we decided that the Plan does not have to pay for the therapy services represented by code 97530 provided on March 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 31, 2020.
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 are not covered as 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. We looked at the file, the Plan's contract and Medicare rules. If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel. If the laboratory assays genes in serial, then the laboratory must submit claims for genes individually. The order by the treating clinician must reflect whether the treating clinician is ordering a panel or single genes, and additionally, the patient's medical record must reflect that the service billed was reasonable and necessary. When more than two codes from this list are submitted for the same beneficiary on the same date of service, the claims processing system will reject every code submitted after the first two services. However, if a lab runs more than two distinct procedural services from this list on a single date of service, then the lab must use the 59 modifier with each additional service billed as an attestation that it is a distinct procedural service. In this case, there were no medical records provided confirming that the labs were billed correctly. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share charged for physician services provided on September 21, 2020.

You asked the Plan to reduce this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost share was charged based on the services billed by the provider and the Plan contract agreement. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract criteria.

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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 30% of the cost for an annual physical exam provided out of network. Your provider billed this as that type of exam and the provider is out of network.

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 cost share charged for physician services provided out of network on September 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuous positive airway pressure titration study (95811).
You asked the Plan to pre-approve the continuous positive airway pressure titration study. You say that this request is medically necessary. The Plan denied your request. The Plan says this service is not covered by the Plan.
The Plan must follow Medicare rules. Medicare rules say that services required by a third party are not covered. 
We looked at the file and Medicare rules. In this case, the case file indicates that this request is not medically necessary and is specifically for driver's license reinstatement. Based on this information, we decided that Medicare rules for coverage of the continuous positive airway pressure titration study have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous positive airway pressure titration study (95811).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this is from my previous surgery. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B IV injections provided on
November 5, 2020.
You asked the Plan to waive the coinsurance for the Part B IV injections. You say that you feel you should not
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan
denied your request. The Plan says you received Part B IV injections on the date of service at issue in this
appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.
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.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received Part B IV
injections on November 5, 2020. You have been asked to pay a 20% coinsurance for the Part B IV injections,
totaling $172.76. The Part B IV 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 the Part B IV injections provided on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 28, 2021.

You asked the Plan to waive the copayment for the office visit. You say that you did not go over anything additional and you don't feel this is right. You say that an office visit charge should not have been billed. 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 $10 copayment for each Medicare-covered primary care visit.

You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that diagnostic services were performed during the visit, which is not considered a preventive service. 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 office visit provided on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Notal visual field testing (0379T).
You asked the Plan to pre-approve Notal visual field testing. You say that this is medically necessary. The Plan
denied your request. The Plan says the requested service is not covered.
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 pre-approve Notal visual field testing. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the record indicates that the enrollee has dry macular degeneration. The medical
record is insufficient to establish the medical necessity and reasonableness of the requested service.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Notal visual field testing have not been met. Therefore, we decided that the Plan
does not have to pre-approve Notal visual field testing (0379T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.

You asked the Plan to pre-approve a stair glide. You say that you are a fall risk, unstable to walk and climb stairs. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. 

While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological services provided on September 24,
2020, to October 23, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the ophthalmological services. You say that you were not aware the provider was
out of network. The Plan denied your request. The Plan says the provider is out-of-network

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 ophthalmological services provided on
September 24, 2020, to October 23, 2020 by an out of network (OON) provider.