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

We decided that the Plan does not have to pay for paramedic intercept services provided on July 20, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the paramedic intercept services provided were not covered. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct Medicare or contractual criteria and that this provider is not a Plan contract provider.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services.

The Plan has confirmed that this provider does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for paramedic intercept services provided on July 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided on June 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an electric hospital bed. You say that you did not know you needed to call the Plan and find a contracted provider. You say that this is a big financial hardship for you. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available to provide this equipment.
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 durable medical equipment provided on June 15, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on
October 16, 2020 and November 17, 2020.
You asked the Plan to pay for the office visit. You say that you were told by Medicare it would be covered and
you should not be responsible for the claims being out-of-network. The Plan denied your request. The Plan says
there is no authorization on file for out-of-network services.
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 office visit provided by an out-of-network
provider on October 16, 2020 and November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (HCPCS Q996, CPT 99152) provided to
the enrollee on September 17, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the denied codes remain not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of the denied codes is:

HCPCS Q9967:

Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml

CPT 99152:

Moderate sedation services provided by the same physician or other qualified health care professional
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an
independent trained observer to assist in the monitoring of the patient's level of consciousness and
physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.

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 medical
records provided do not include documentation of the specific concentration amount of low osmolar contrast
material administered on September 17, 2020, therefore Q9967 cannot be verified. The medical records
provided do not include documentation of the presence of an independent trained observer to assist in the
monitoring of the enrollee's level of consciousness and physiological status; initial 15 minutes of intra-service
time, patient aged 5 years or older, therefore CPT 99152 cannot be verified as being performed on September
17, 2020.

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 for anesthesia services (HCPCS Q996, CPT 99152) provided to the enrollee on September 17,
2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services.
You asked the Plan to waive the copayment for the ambulance services. You say that you had open heart surgery then was in a coma. Your medical expenses have been a lot. You need assistance and can't pay $325. You had no idea the ambulance bill would cost so high. The Plan denied your request. The Plan says you were charged this cost sharing 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 $325 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $325 for these services. 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 ambulance services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation provided on July 21, 2020.

You asked the Plan to pay for the ambulance transportation. The Plan denied your request. The Plan says this is not a covered destination.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

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 ambulance transportation. Our reviewer says that the requested ambulance transportation is not medically reasonable and necessary. Our physician reviewer found that there is no documentation that a stretcher van was contraindicated for this enrollee on July 21, 2020. There is no documentation that only a fully equipped ambulance could have provided for safe transport. There is no documentation that a stretcher van was contraindicated for this enrollee. The ambulance transport on July 21, 2020, was not medically reasonable and necessary for the enrollee.

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 ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation provided on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on October 29, 2020.
You asked the Plan to pay for the office visit. You say that the treatment provided was medically necessary and an emergency case. You say that the claim should be processed in-network. The Plan denied your request. The Plan says prior authorization was required but 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 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 office visit provided by an out-of-network provider on October 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on August 4, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99291 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 30-74 minutes of critical care services for the billed date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services rendered on August 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on November 24, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation. We looked at the file and Medicare rules. In this case, the medical records do not show that the results of the test would be used in the management of the enrollee's specific medical problems. 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 lab testing services provided on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 5, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because you were told that the copayment waiver was still in effect through December 2020. You state that if you had known you would owe a copayment for in person specialist visits you would have done a telehealth visit instead. 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 $50 copayment for specialist services. You received a specialist visit on November 5, 2020. Specialist visits are subject to cost-sharing charges and are not included in the COVID-19 waiver. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for a specialist visit. A specialist 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 a specialist visit provided on November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for sneakers provided on November 27, 2020.
You asked the Plan to reimburse you for the sneakers. You say that you use the sneakers to walk around on hikes and trails and this should qualify as exercise equipment because of the letter you received from the Plan during COVID-19. The Plan denied your request. The Plan says per the temporary COVID-19 Fitness Equipment Reimbursement policy, examples of exercise equipment include treadmills, exercise bikes, elliptical, free weights, resistance bands, weight stations (such as bow flex), jump ropes, yoga mats and subscription services to online classes. Therefore, we are unable to approve your request because sneakers are not a covered benefit under the temporary COVID-19 Fitness Equipment Reimbursement policy.
The Plan contract offers a supplemental Wellness Allowance and a temporary COVID-19 Fitness Equipment Reimbursement policy that does not include coverage for sneakers. We looked at the file and the Plan's rules. The file shows that sneakers are not covered under the Plan's Wellness Allowance or the Plan's COVID-19 Fitness Equipment Reimbursement policy. Therefore, we decided that the Plan does not have to reimburse you for sneakers provided on November 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment provided on August 17, 2020.

You asked the Plan to pay for the cardiovascular risk assessment. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular disease screening tests are only covered for certain indications.

The laboratory services at issue in this appeal were requested solely for screening purposes. While Medicare covers cardiovascular disease screening tests for certain indications, the documentation does not support that the enrollee met criteria for the services rendered. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment provided on August 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for nasal repair services (CPT 30465) provided to the enrollee on June 24, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the service 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. In this case, the CPT Code Manual definition of code 30465 is "Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction)." 

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 based on the medical records provided, procedure CPT 30465 was performed with another separately identifiable procedure with a higher dollar value and listed as the primary procedure, therefore CPT 30465 should have been submitted with a 51 modifier. 

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 for nasal repair services (CPT 30465) provided to the enrollee on June 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on August 31, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed services cannot be verified.

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 15261 is full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure). We find that the code at issue was not billed with a valid primary procedure code.

The CPT Code Manual definition of code 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. We find that this CPT code is not supported in the medical record. Specifically, there is a more comprehensive code to describe tissue rearrangement of the nasal area. 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 surgery services provided on August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on January 6,
2021.
You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan
says the Plan paid the correct benefit allowance of $400.00.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan paid the correct benefit allowance of
$400.00. Therefore, we decided that the Plan does not have to pay for eyeglasses provided by on January 6,
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided from August 11, 2020, to August 14, 2020.

You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was stable for transfer.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient care. Our reviewer says that the requested inpatient care was not medically reasonable and necessary in this case. Our physician reviewer found that by 10:01 a.m. on August 11, 2020, the enrollee was stable for ambulance transport with monitoring to a Plan facility. The enrollee was stable for transfer because she was stable post-operatively, her wounds and dressings were clean, dry, and intact, and she had normal neurovascular exams. The plan was to continue antibiotics, pain control, and to start physical therapy/occupational therapy, which all could have been done at a Plan facility. The post-stabilization care services 10:01 a.m. on August 11, 2020, to August 14, 2020, were not medically necessary or reasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. 

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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient care provided from August 11, 2020, to August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal care services (T1019) provided on September 1, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code T1019 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the personal care services (T1019) provided on September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (AWV) you had on December 16,
2020.

You asked the Plan to pay for the AWV. The Plan denied your request. The Plan says the benefit limit has been
exceeded.

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once
every 12 months.

Based on review of the file, an AWV was provided on March 3, 2020, less than 12 months prior to the visit at
issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit (AWV)
you had on December 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 24, 2020.
You asked the Plan to pay for the lab services. You say that you were not told this is not a covered service. The Plan denied your request. The Plan says screening tests are 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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on September 24, 2020.