Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the services can safely be received in another setting, such as a skilled
nursing facility.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 11, 2020, by an OON provider.You asked the Plan to pay foranticoagulant management. You say that these services should be covered due to the enrollee's condition and the pandemic coronavirus emergency.The Plan denied your request. The Plan says rules for payment have not been met.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 forthe medical services provided on September 11, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) provided
September 4, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you don't feel that you should be
charged another copay to get test results that could have been told to you over the phone. The Plan denied your
request. The Plan says the claim processed and the correct copayment applied per the Evidence of Coverage.
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 $35 for
each specialist visit for Medicare covered services.
You have been asked to pay $35 for the office visit. The office visit falls within the Physician/Practitioner
services, including doctor's office visits benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment
for the outpatient office visit (99213) provided September 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services with no transport provided on September 30, 2020.You asked the Plan to pay forthe ambulance services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says ambulance services are not covered when there is no transport.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 30, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services with no transport provided on September 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested LTACH care is not considered medically reasonable and necessary in this case. Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility.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 LTACH services have not been met.Therefore, we decided that the Plan doesnot have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services rendered on July 8, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says procedure code 61782 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 61782 is stereotactic computer-assisted (navigational) procedure; cranial, extradural (List separately in addition to code for primary procedure).We find that CPT code 61782 is not supported in the medical record.Specifically, this is an add-on code that was not billed with a required primary procedure code. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT codes 31295, 31298, and 31255 is 1. You billed 2 units of each code, exceeding the MUE. 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 forthe surgical services rendered on July 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forpneumatic compressor, segmental home model without calibrated gradient pressure (E0651) and segmental pneumatic appliance (E0667).You asked the Plan to pay forintermittent limb compression device and appliance. You say that you have attachedall the supporting documentation deeded to finish processing the claim.The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for the requested services.The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.We asked our physician reviewer to carefully review the case file and apply therelevant Medicare rules to determine if the Plan was correct in denying the request to pay for intermittent limb compression device and appliance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary inthis case. Our physician reviewer found the review indicates that the physical exam documents 1+ lower extremity edema and varicosities, but no ulcers. Per the coverage criteria, pneumatic devices are covered only for the treatment of lymphedema or for the treatment of chronic venous insufficiency with venous stasis ulcers. The review indicates the medical records provided do not meet the requirements listed in the NCD  for Medicare coverage.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intermittent limb compression device and appliance have not been met.Therefore, we decided that the Plan does not have to pay forpneumatic compressor, segmental home modelwithout calibrated gradient pressure (E0651) and segmental pneumatic appliance (E0667).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services with CPT code 49650 provided on December 19, 2019.You asked the Plan to pay forCPT code 49650. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed.The Plan must follow Medicare rules. Medicare rules say that claims submittedwhere the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT code 49650 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of CPT code 49650 have not been met.Therefore, we decided that the Plan does not have to pay forthe surgical services with CPT code 49650 provided on December 19, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on August 26, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare website shows the enrollee was enrolled in hospice from August 17, 2019,through November 22, 2019. In accordance with Medicare guidelines, the provider needs to bill Original Medicare,using the proper modifiers, for services rendered. The Plan notes it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage enrollee on hospice.Medicarerules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on August 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fortwo crowns -porcelain fused to high noble metal (D2750) and a limited oral evaluation -problem focused (D0140) provided on February 20, 2020, and March 24, 2020.You asked the Plan to pay forthree crowns and a limited oral exam. You say that the services were medically necessary.The Plan denied your request. The Plan says limited oral evaluation are not a covered service and crowns are allowed once per calendar year.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. The plan covers one crown per a calendar year and does not cover limited oral evaluations.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. Specifically, limited oral evaluations are not a covered benefit and you have exhausted your benefits for crowns for the calendar year.Therefore, we decided that the Plan does not have to pay forthree crowns -porcelain fused to high noble metal (D2750) and a limited oral evaluation -problem focused (D0140) provided on February 20, 2020, and March 24, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan does not have to waive the $23.18 cost share charged for medical supplies provided
on May 6, 2020.
You asked the Plan to waive this coinsurance. You say that you do not believe this cost share is correct. The
Plan denied your request. The Plan says this cost share was applied per the Plan contract agreement. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that they partially overturned the enrollee's
request to waive the $45 specialist copayment and reduced the enrollee's coinsurance to 20%. The 20%
coinsurance amount (20% of allowed amount $115.90 = $23.18) is correct, but the DME benefit is incorrect.
The 20% coinsurance should have been applied to HCPCS code G0249 under the medical supplies benefit, not
durable medical equipment. The Plan says that Medicare guidelines clearly states that HCPCS Code G0249 is
not durable medical equipment. Based upon the verification that the claim processed correctly and had already
partially overturned applying the 20% coinsurance to medical supplies, which totals $23.18, this should remain
denied.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan
clearly says that you must pay 20% coinsurance for medical supplies. 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 $23.18 cost
share charged for medical supplies provided on May 6, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on June 17, 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 based in the enrollee's hospice election, this claim should be submitted to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on June 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services with CPT code 86077 provided on
September 20, 2020.
You asked the Plan to pay for CPT code 86077. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 86077 is 1. You billed 2 units of this code, exceeding the MUE. Based on
this information, we decided that Medicare rules for coverage of CPT code 86077 have not been met.
Therefore, we decided that the Plan does not have to pay for the laboratory services with CPT code 86077
provided on September 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe crown and core buildup you received on August 18, 2020.You asked the Plan to pay forthe dental services. The Plan denied your request. The Plan says this is not 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 services are either subject to a benefit limitation or are not among those covered under this benefit. The Plan covers one crowns per calendar year. The records show that you were provided a covered crown on April 9, 2020. The requested crown exceeds the benefit limit. Additionally, the Plan only covers those dental serviceslisted in the Evidence of Coverage. Core buildup services are not covered.Therefore, we decided that the Plan does not have to pay forthe crown and core buildup you received on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services provided on May 12, 2020.
You asked the Plan to waive the copayment for the specialist services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received services provided by a specialist on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for each specialist visit for Medicare covered services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received specialist services on May 12, 2020. You have been asked to pay a $50 copayment for the specialist services. The specialist services fall within the Outpatient hospital 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 the specialist services provided on May 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe filling (D2393) provided on June 30, 2020.You asked the Plan to pay forthe dental services. You say that this is the second denial that you have gotten. You say that since you let the first one go, this one should be covered. You also say that you were disappointed that you were transferred so many times and no one could help you.The Plan denied your request. The Plan says fillings are not a covered service. The Plan also says you were not enrolled in the supplemental dental rider on the date of service.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 forthe filling (D2393) provided on June 30, 2020.Your complaint aboutbeing transferred multiple times on the phone with no help 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe inpatient hospital services provided from July 13, 2020 through July 16, 2020.You asked the Plan to waive the copay forthe inpatient hospital services. You say that you should not be responsible for this copay.The Plan denied your request. The Plan says that the claim was processed 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 $315 copay for days 1-6 of each Medicare-covered hospital stay. You have been asked to pay a $315 copay for the inpatient hospital services. The inpatient hospital services fall within the days 1-6 of each Medicare-covered hospital stay 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 forthe inpatient hospital services provided from July 13, 2020 through July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider from July 17, 2020, to July 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are
available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
from July 17, 2020, to July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 29, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 forthe medical services provided on May 29, 2020 by anout of network (OON) provider.