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

We decided that the Plan does not have to waive the copayment for outpatient hospital clinic visits provided on
August 1, 2019 and August 15, 2019.
You asked the Plan to waive the copayment for clinic visits. You say that the provider told you that they did
not need to see your insurance card and there was no charge. 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 $150
copayment for each non-surgical hospital clinic visit. There were 2 visits, resulting in a total copayment
obligation of $300.
You have been asked to pay $150 copayment for each clinic visit. Clinic visits fall within the Outpatient
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 outpatient hospital clinic visits provided on
August 1, 2019 and August 15, 2019.
Your complaint regarding receiving inaccurate information about the cost-share for these services is considered
to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please
contact the Plan for more information about your grievance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three retainer crowns and three pontics provided on November 19, 2019.
You asked the Plan to pay for the retainer crowns and pontics. You say that these services were provided due to an accident, and you cannot live without front teeth. You also say that you are retired and living on a fixed income. The Plan denied your request. The Plan says your contract does not cover these services.
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. The Plan confirmed that you do not have optional supplemental dental coverage. Therefore, we decided that the Plan does not have to pay for the three retainer crowns and three pontics provided on November 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS HF system for the enrollee.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health
problem.
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 the system. Our reviewer says that the
requested system is not considered medically reasonable and necessary in this case. Our physician reviewer
found in this circumstance therapy change based on data obtained from a CardioMEMs device has been
demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy.
Moreover, concerns have been raised about potential bias in this trial calling into question the results.
Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and
not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met
since the device should still be considered experimental or investigational.
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 system have not been met. Therefore, we decided that the Plan does not
have to pre-approve the CardioMEMS HF system for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for urinary intermittent catheter with insertion supplies (A4353)
provided February 26, 2020.
You asked the Plan to pay for the urological supplies. You say that the medical records should support the
necessity of the service in dispute. The Plan denied your request. The Plan says the billed supply code cannot
be verified.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid proof of delivery, or relevant medical records which support medical
necessity for the supplies provided in this case. The records did not include a signed delivery sheet with proof
of delivery. 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 urinary intermittent catheter with
insertion supplies (A4353) provided February 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services rendered on February 19,
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 the services are not separately payable.
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately
payable when furnished in different payment localities.
We looked at the file and Medicare rules. The file shows that the PC is not separately payable, as the global
procedure was also billed and paid by the Plan. The file does not show that the PC was performed in a separate
payment locality. 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 surgical pathology services rendered on
February 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Linzess capsules.
You asked the Plan to pre-approve the Linzess capsules. You say that this medicine works for you. The Plan denied your request. The Plan says this drug is not covered for your condition by 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 Linzess capsules.
Benefits for the Linzess capsules 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation and problem focused limited oral evaluation provided on February 19, 2020.
You asked the Plan to pay for the cone beam CT capture and interpretation and problem focused limited oral evaluation. The Plan denied your request. The Plan says the treating provider opted out of Medicare, effective April 20, 2018 to April 20, 2022.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the cone beam CT capture and interpretation and problem focused limited oral evaluation provided on February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a premium hip kit including an extra-long shoehorn, sock aid, no-tie shoelaces, bath sponge, dressing stick and Easireach.
You asked the Plan to pre-approve a premium hip kit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The items at issue in this appeal does not serve a purpose that is primarily medical in nature. These items are available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a premium hip kit including an extra-long shoehorn, sock aid, no-tie shoelaces, bath sponge, dressing stick and Easireach.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for vascular embolization (37243) and catheter placement (36248) provided on February 28, 2020. You asked the Plan to pay for vascular embolization and catheter placement. You say that these procedures should be covered. The Plan denied your request. The Plan says these procedures were billed with an incorrect Place of Service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that the billing of this claim is not supported in the record. Specifically, these services were billed with a Place of Service of 21, indicating the services were provided in an inpatient hospital. However, the record shows that the enrollee was not admitted as inpatient on this date of service. Based on this information, we decided that Medicare rules for coverage of vascular embolization and catheter placement have not been met. Therefore, we decided that the Plan does not have to pay for vascular embolization (37243) and catheter placement (36248) provided on February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning services (99497) provided on October
23, 2019.
You asked the Plan to pay for the advance care planning. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation submitted does 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 99497 is advance care planning including the explanation
and discussion of advance directives such as standard forms (with completion of such forms, when performed),
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient,
family member(s), and/or surrogate.
We find that CPT code 99497 is not supported in the record. Specifically, the record does not indicate that 30
minutes of advance care planning was rendered on the billed date of service. Based on this information, we
decided that Medicare rules for coverage of the advance care planning have not been met. Therefore, we
decided that the Plan does not have to pay for advance care planning services (99497) provided on October 23,
2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Aranesp. Our reviewer says that the enrollee has not met the step therapy requirements for coverage of Aranesp. Our physician reviewer found that there is no evidence that the enrollee is allergic to or intolerant of Retacrit. There is no evidence that the enrollee has tried and not responded to Retacrit. There is no documentation as to why Retacrit would not be expected to be safe and effective 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
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 these services are medically necessary.The Plan denied your request. The Plan says that the member can safely receive care needed in a lower level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to currently be able to perform, fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit (99213). You say that you would like reconsideration because this provider is in-network with the Plan. The Plan denied your request. The Plan says utilization of in-network providers is required when possible and available.
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 has network providers available who can provide 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 medical services provided on January 6, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient mental health care stay provided from February 2, 2020 to February 7, 2020.
You asked the Plan to pay for inpatient mental health stay. You say that you are of the opinion that these inpatient services were medically necessary. The Plan denied your request. The Plan says the denial of payment for inpatient mental health care is correct, because the enrollee did not require inpatient level of care and the appropriate level of care would have been outpatient services.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health stay. Our reviewer says that this inpatient psychiatric stay does not meet the Medicare criteria for coverage. Our physician reviewer found that, based upon review of the records provided, it was not expected that this enrollee would improve in a reasonable period of time as she did not have dangerousness to self or others, auditory or visual hallucinations, or behaviors threatening acute safety. She was cooperative and compliant with treatment. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purposes of diagnosis. The record submitted does not include an individualized treatment plan, however the entire record is not present. It does appear that the services were supervised and evaluated by a physician.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health stay have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient mental health care stay provided from February 2, 2020 to February 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS non-emergency ambulance service (A0428) and
ground mileage (A0425) provided July 23, 2019.
You asked the Plan to pay for the ambulance services. You say that this trip should be considered an
emergency transportation but it was billed as a nonemergency transportation. The Plan denied your request.
The Plan says transportation to a physician's office is not covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when
they meet certain origin and destination requirements. A doctor's office is not a covered destination.
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.
Therefore, we decided that the Plan does not have to pay for the BLS non-emergency ambulance service
(A0428) and ground mileage (A0425) provided July 23, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99283) provided on February 8, 2020.
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99284 should not be reported with a related service during the defined time frame.
The Plan must follow Medicare rules. Medicare rules say that physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Specifically, the record indicates that another evaluation and management code was billed and paid by the Plan for the billed date of service. In this case, CPT code 99283 has been billed by a provider in the same group and with the same specialty as the paid evaluation and management service. Therefore, we decided that the Plan does not have to pay for an emergency department visit (99283) provided on February 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on February 3, 2020.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you didn't know you had to use a network provider. You say that from now on you will use a dentist in the network. The Plan denied your request. The Plan says payment cannot be issued for services performed by a provider that has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe hospital outpatient clinic visit and the office visit provided on March 6, 2020.You asked the Plan to waive the copayments forthe hospital outpatient clinic visit and office visit. You say that you feel like you should only be responsible for the $5 office visit copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for all other in-network Medicare-covered outpatient hospital services and a $5 copayment for each in-network Medicare-covered visit with a primary care physician or, under certain circumstances, a nurse practitioner or physician assistant or non-physician health care provider. You have been asked to pay a $20 copayment for the hospital outpatient clinic visit and a $5 copayment for office visit. The hospital outpatient clinic visit falls within the "Outpatient hospital services" benefit category. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were billed byboth the facility and the provider. 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 decidedthat the Plan does not have to waive the copayments forthe hospital outpatient clinic visit and the office visit provided on March 6, 2020