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

We decided that the Plan does not have to waive the coinsurance for the infusion provided on October 29, 2020.
You asked the Plan to waive the coinsurance for the infusion. You say that the Plan is being overcharged and you are unable to afford your responsibility. 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 20% coinsurance for in-network Medicare Part B covered drugs. You have been asked to pay $86.14 which is 20% of the allowed amount for the infusion. The allowed amount is $430.68. ($430.68 x 20% = $86.14). The infusion 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 infusion provided on October 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eye exam (92014) provided November 10, 2020.
You asked the Plan to pay for the routine eye exam. You say that you would like the service covered. The Plan denied your request. The Plan says the service was not provided by a network provider and therefore it is not covered under your benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are provided by a network provider. We looked at the file and the Plan's rules. Out-of-network services are not covered. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for the routine eye exam (92014) provided November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified adjunctive procedure (D9999), the prediagnostic
adjunctive testing (D0431), and the vertical bitewings (D0277) provided on November 9, 2020.
You asked the Plan to pay for the dental services. You say that the bitewing x-rays are covered. The Plan
denied your request. The Plan says the unspecified preventive service and the pre-diagnostic adjunctive testing
are not listed as covered services. The Plan also says that the provider was advised prior to the date of service
that the vertical bitewings would not be covered.
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
unspecified adjunctive procedure (D9999), the pre-diagnostic adjunctive testing (D0431), and the vertical
bitewings (D0277) provided on November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on July 30, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claims was submitted after the timely filing limit.
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 services was not filed until October 30, 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 services provided on July 30, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the copayment for an outpatient surgery provided on November 20, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with this copayment. The Plan denied your request. The Plan says that the correct copayment has been applied.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has failed to forward the correct EOC, making it impossible to determine a decision. Therefore, we decided that the Plan has to waive the copayment for an outpatient surgery provided on November 20, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on October 4, 2020.
You asked the Plan to waive the copayment for an emergency room visit. You say that you should not have to pay this because you were admitted. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care/in-network/emergency services. You have been asked to pay a $90 copayment for an emergency room visit. An emergency room copayment is not waived even if admitted to the hospital; therefore, the correct copayment has been. An emergency room visit falls within the emergency care/in-network/emergency 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 an emergency room visit provided by a participating provider on October 4, 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 November 11, 2020, to November 13, 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 quality of care you 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). Your contract with the Plan clearly says that you must pay a $492 copayment for days 1-4 for inpatient hospital coverage. You had an inpatient hospital stay from November 11, 2020, to November 13, 2020. Therefore, you are responsible to pay a $492 copayment for days 1-2 (November 11, 2020, to November 12, 2020). $492 (copayment) x 2 (inpatient days) = $984. You have been asked to pay the total copayment amount of $984 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital coverage 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 an inpatient hospital stay from November 11, 2020, to November 13, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, two increments of first 15 minutes of deep sedation/general anesthesia, each additional 15 minute increment of deep sedation/general anesthesia, extraction, therapeutic parenteral drugs and adjunctive procedure provided on October 20, 2020.
You asked the Plan to pay for the comprehensive oral evaluation, deep sedation/general anesthesia services, and adjunctive procedure. You say that these services were provided on an emergency basis. The Plan denied your request. The Plan says the treating provider is not enrolled in Medicare.
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 covered when they are received from a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, two increments of first 15 minutes of deep sedation/general anesthesia, each additional 15 minute increment of deep sedation/general anesthesia, extraction, therapeutic parenteral drugs and adjunctive procedure provided on October 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the lumbar spine, without contrast (72148).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says an MRI of the lumbar spine is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 this service. Our reviewer says that an MRI of the lumbar spine is not medically necessary. Our physician reviewer found that the enrollee was diagnosed with lumbar radiculopathy. The enrollee has not had a response to physician-guided treatment. She had a computed tomography (CT) scan that showed mild multilevel degenerative disc disease with facet arthropathy. She had physical and massage therapy; however, this increased her pain. A magnetic resonance imaging (MRI) scan of the lumbar spine was requested for further evaluation. However, there is no specific clinical rationale provided for this request. The enrollee's diagnosis was established with the CT scan of the spine. The review has determined that the requested MRI is not medically necessary or 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the lumbar spine, without contrast (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating provider on November 17, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you should not have a copayment for an annual wellness exam. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for physician/practitioner services/in-network/primary care physician. You have been asked to pay a $10 copayment for an office visit. The office visit that was provided was not an annual wellness exam; therefore, the correct copayment has been applied. An office visit falls within the physician/practitioner services/in-network/primary care physician 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 an office visit provided by a participating provider on November 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee is ready for rehab. The Plan denied your request. The Plan says the records show that the enrollee's care is not complex, and the enrollee does not need a team of providers. The Plan also says that the enrollee can safely receive the services they 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 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. Our physician reviewer also found that the enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this enrollee's functional level or tolerance for therapy (given her shortness of breath noted in therapy with exertion) requires an intensive level in an IRF.

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 the acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Buprenorphine patch.

You asked the Plan to pre-approve the Buprenorphine patch. You say that you would like reconsideration because the member has tried and failed non-steroidal anti-inflammatory drugs. The Plan denied your request. The Plan says this does not fall under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Buprenorphine patch.

Benefits for the Buprenorphine patch 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on March 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the limit for filing has expired.
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 services was not filed until August 27, 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 services provided on March 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xolair.

You asked the Plan to pre-approve Xolair. You say that you would like reconsideration because the pharmacy bills the member for the copayment and the member receives the injections at the providers office. The Plan denied your request. The Plan says this is not a Medicare Part B benefit.

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 Xolair.

Benefits for Xolair 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit and physician services
provided by an out-of-network provider on August 24, 2020, to October 13, 2020.
You asked the Plan to waive the deductible for an office visit and physician services. You say that you were
told that you would not be charged for out-of-network now in other states. The Plan denied your request. The
Plan says the correct deductible has been applied.
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 $1,500 deductible for physician/practitioner services/out-of-network.
The item or service you asked the Plan to waive the deductible for falls within the benefit category
physician/practitioner services/out-of-network. The Plan has followed Medicare rules by clearly disclosing in
the contract that there is a $1,500 deductible for physician/practitioner services/out-of-network. This cost
sharing is a contractual obligation that had not been met at the time an office visit and physician services was
received on August 24, 2020 to October 13, 2020. The total amount you are being asked to pay is $574.56.
Therefore, we decided that the Plan does not have to waive the deductible for an office visit and physician
services provided by an out-of-network provider on August 24, 2020, to October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided October 9, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the requested item was medically necessary. The Plan denied your request. The Plan says the patient did not receive a video or telephonic visit by the ordering physician in order to warrant the code billed.
The Plan follows Medicare rules. Medicare rules say that the spinal orthosis is subject to the criteria listed 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 pay for the lumbar-sacral orthosis. Our reviewer says that the orthosis provided was not medically necessary and reasonable. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation and a credible physical examination of the back. 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided October 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic custom molded shoe (A5501) and shoe insert (A5513).

You asked the Plan to pay for diabetic custom molded shoe and shoe insert. You say that these items were medically necessary. The Plan denied your request. The Plan says the billed services were not supported.

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 physician order. In this case, the physician order is dated after the items were delivered. Therefore, the physician order was not completed prior to the items being delivered and is invalid. 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 for diabetic custom molded shoe (A5501) and shoe insert (A5513).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on May 23, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely tiling limit.
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 services was not filed until October 8, 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 services provided on May 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an esophagogastroduodenoscopy (43235) and a sigmoidoscopy (45330) provided on May 20, 2020
You asked the Plan to pay for an esophagogastroduodenoscopy and a sigmoidoscopy. You say that these codes are supported. The Plan denied your request. The Plan says these services are not documented on the billed date of service.
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 codes 43235 and 45330 are not supported in the medical record. Specifically, the submitted medical records indicate that these procedures were performed on May 19, 2020. There is no documentation showing that these services were performed on the billed date of service, May 20, 2020. Based on this information, we decided that Medicare rules for coverage of an esophagogastroduodenoscopy and a sigmoidoscopy have not been met. Therefore, we decided that the Plan does not have to pay for an esophagogastroduodenoscopy (43235) and a sigmoidoscopy (45330) provided on May 20, 2020.