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 visit provided on January 28,
2021.
You asked the Plan to waive the copayment for the specialist visit. You say that you do not know why you
have to pay a copayment for a visit from the doctor. 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 each specialist visit, including outpatient clinic visits.
You have been asked to pay a $35 copayment for the specialist visit. The specialist's visit falls within the
"Outpatient hospital services" benefit category. The record shows you were notified that you were admitted to
outpatient observation and that for Part B services, you generally pay a copayment for outpatient hospital
service you get.
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 visit provided on January 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the echocardiogram and the duplex scan provided on June 17, 2020.
You asked the Plan to waive the copayments for the echocardiogram and the duplex scan. You say that there were two procedures done on the same day. You say they are both echograms and you do not understand why you need to pay two copayments. 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 $155 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility (such as a radiology center or medical clinic). You have been asked to pay a $302.94 copayment for the echocardiogram and the duplex scan. The echocardiogram and the duplex scan fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows the echocardiogram and the duplex scan are considered separate services. See chart below.
Date of Service
Service
Allowed Amount
Copayment
Member Liability
June 17, 2020
Echocardiogram
$147.94
$155
$147.94
June 17, 2020
Duplex scan
$156.64
$155
$155
Total
$302.94
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 the echocardiogram and the duplex scan provided on June 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on December 2, 2020, to December 8, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment you are being charged is 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 a $200 copayment per day, for days 1-6 of inpatient hospital care. Your contract with the Plan also clearly says that you pay $0 for additional hospital days. You have been asked to pay a $200 copayment per day for inpatient hospital care ($200 x 6 days = $1,200). The EOC confirms that $200 per day is the required copayment for this 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 inpatient hospital care provided on December 2, 2020, to December 8, 2020.
Your complaint about not obtaining information from the rehabilitation facility is not a valid appeal for medical
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on February 18, 2021.You asked the Plan to pay forthe office visit. You say that after 1 treatment you no longer had extreme pain.The Plandenied your request. The Plan says this service is not covered by Medicare when rendered by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The file shows that you received manual manipulation and an office visit on the date of service at issue. The Plan processed and paid for the manual manipulation. The office visitat issue is not manual manipulation of the spine.An office visit, when provided by a chiropractor, is not a covered service. Therefore, we decided that the Plan does not have to pay forthe office visit provided on February 18, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided from July 16, 2019.

You asked the Plan to pay for the services provided. You say that the service is medically indicated for the enrollee's surgery. The Plan denied your request. The Plan says this benefit is excluded from the enrollee's coverage.

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 95941 is continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure).

We find that CPT code 95941 is not valid for Medicare purposes. Medicare uses another code for the reporting of and payment for these services. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided from July 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on February 25, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you needed to find a new dentist because the contract between your prior dentist and insurance was cancelled. You also say that you feel the Plan should have to pay for this service. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.
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, comprehensive oral evaluation is limited to one procedure code every three years. The record shows that you received a comprehensive oral evaluation on July 16, 2019 and your comprehensive oral evaluation benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the testing of the autonomic nervous system function (95921, 95923) provided on October 20, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $0 copayment for Medicare-defined preventive diagnostic procedures and tests. Additionally, you pay a $50 copayment for all other diagnostic procedures and tests.
You have been asked to pay a $50 copayment for the diagnostic testing provided. 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 testing of the autonomic nervous system function (95921, 95923) provided on October 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the chest, two views (71046) rendered by the out of network (OON) provider on September 18, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the x-ray exam of the chest, two views (71046) rendered by the out of network (OON) provider on September 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the computed tomography (CT) scan provided on January 21, 2021.
You asked the Plan to waive the copay for the CT scan. You say that the scan was required prior to your procedure. The Plan denied your request. The Plan says the claim processed and paid with a copay.
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 $150 copay for diagnostic radiological services performed at a contract facility. The records show that the provider has agreed to reimburse the cost of the scan, minus the copay. You have been asked to pay a $150 copay for the CT scan. The CT scan falls 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 copay for the computed tomography (CT) scan provided on January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and an intraoral periapical radiographic image (D0220) provided on March 2, 2021.
You asked the Plan to pay for a limited oral evaluation, and an intraoral periapical radiographic image. You say that you want the Plan to pay for the services. The Plan denied your request. The Plan says the services at issue 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 a limited oral evaluation (D0140), and an intraoral periapical radiographic image (D0220) provided on March 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 22, 2020, to August 24, 2020.

You asked the Plan to pay for acute inpatient hospital care provided to the enrollee. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says Medicare criteria for inpatient care were not met beyond July 22, 2020. Maximus overturned the Plans denial. The Plan requested a reopen and stated that as of July 22, 2020 the concentration was for social issues and placement and did not involve medical care. The Plan states the physician progress note dated July 22, 2020 stated they were now working the case management, family, and a social worker to arrange a safe discharge plan given she the enrollee required 24-hour care moving forward. Additionally, the provider only requested coverage for July 12, 2020 to July 22, 2020, when the enrollee was medically stable for discharge. The provider confirmed the remainder of stay was used to work through arranging placement. The enrollee actually disenrolled from the Plan, established state residency and applied for Medicaid and guardianship. The enrollee disenrolled officially from the Plan on August 1, 2020 and was discharged to long-term care on August 24, 2020. The Plans position is the care provided beyond July 22, 2020 was strictly custodial for placement and social work purposes.

The Plan is correct in this case. 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. The Plan paid for inpatient services provided from July 12, 2020, to July 21, 2020 as those were the dates in which active treatment was being provided. As of July 22, 2020, the care clearly became custodial in nature for social placement, which is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 22, 2020, to August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 4 and 5.
You asked the Plan to pre-approve the crowns. You say that new crowns are needed to fix the open margins and contacts. You also say that without replacing the crowns, your teeth will become decayed due to bacteria and you will lose these teeth. The Plan denied your request. The Plan says these services exceed the maximum count allowed per period.
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, crown (D2740) is limited to one procedure per tooth every five plan years. The record shows that you received crowns (D2740) on tooth #'s 4 and 5 on December 8, 2020 and your crown (D2740) benefits for tooth #'s 4 and 5 have been exhausted. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 4 and 5.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services with care from a nurse, home health aide, physical therapist, and occupational therapist to be provided by a non-Medicare certified provider.
You asked the Plan to pre-approve the home health services. You say that the services are necessary. The Plan denied your request. The Plan says this provider is not certified with Medicare; however, the Plan identified Medicare certified home health providers that can perform the services.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Medicare rules do not allow coverage of home health services like a nurse, home health aide, physical therapy, and occupational therapy unless the agency providing the care is Medicare certified. The provider you are requesting is not a home health agency and is not Medicare certified. The requested services from non-Medicare certified provider cannot be covered by Medicare or the plan. Therefore, we decided that the Plan does not have to pre-approve home health services with care from a nurse, home health aide, physical therapist, and occupational therapist to be provided by a non-Medicare certified provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the initial nursing facility care (99304).

You asked the Plan to pay for the initial nursing facility care. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that the services are not supported without the required documentation.

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. It is the burden of the Health Plan to substantiate their denial with evidence. The Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the initial nursing facility care (99304).

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on February 17, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that you thought that when you switched to the Plan that you would not owe any copayments. 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 $0 copayment for mammography and ultrasounds and a $195 copayment for all other diagnostic and nuclear medicine radiological services. You have been asked to pay the allowed amount of $140.36, which is less than the $195 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies 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 a CT scan provided on February 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve additional routine transportation trips

You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says you have exhausted the benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 12 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we found that
the enrollee has the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to approve additional routine transportation trips
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehab to monitor their vitals for subtle changes that may lead to readmission. The Plan denied your request. The Plan says that the enrollee may be able to have the care needed, at an alternate level, like skilled nursing.
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.
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for congestive heart failure, septicemia and respiratory failure. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.