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

We decided that the Plan does not have to pre-approve lumbar spinal fusion (63047, 22840, 22853, 20930).
You asked the Plan to pre-approve lumbar spinal fusion. You say that this is medically necessary because conservative treatment would not be effective. The Plan denied your request. The Plan says the enrollee does not have a motor or sensory deficit.
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 lumbar spinal fusion. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documented instability, fracture, or lesion. There is no documentation of a recent and adequate trial of physical therapy. Surgery is not indicated at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar spinal fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar spinal fusion (63047, 22840, 22853, 20930).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora biopsy provided on September 27, 2019.You asked the Plan to waive the copayment fora biopsy. You say that you did not receive services.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 $150 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you had a biopsy on September 27, 2019. Therefore, you are responsible to pay the $150 copayment. You have been asked to pay a $150 copayment for a biopsy. A biopsy falls within the outpatient surgery and other medical 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 fora biopsy provided on September 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound rendered on November 18, 2019.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 76700 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 76700 is ultrasound, abdominal, real time with image documentation; complete.We find that CPT code 76700 is not supported in the medical record. Specifically, there is no documentation of an abdominal ultrasound. 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 ultrasound rendered on November 18, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural steroid injections to the L5-S1 and L4-L5.
You asked the Plan to pre-approve lumbar epidural steroid injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that lumbar epidural injections are only covered for certain indications. 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 lumbar epidural steroid injections. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain with radiculopathy. She has undergone 3 sets of epidural steroid injections on January 7, 2020, January 21, 2020, and February 4, 2020, as well as diskography on March 3, 2020. The request exceeds utilization criteria and is therefore, not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar epidural steroid injections have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural steroid injections to the L5-S1 and L4-L5.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the astigmatism-correcting IOL you received on October 29,
2019.
You asked the Plan to pay for the services. You say that you were not given the correct codes from the
provider. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a
conventional IOL.
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatismcorrecting
feature of an IOL. Therefore, we decided that the Plan does not have to pay for the astigmatismcorrecting
IOL you received on October 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on October 16, 2019.
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 74177 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 74177 is computed tomography, abdomen and pelvis; with contrast material(s). We find that CPT code 74177 is not supported in the medical record. Specifically, there is no documentation that a CT scan of the abdomen/pelvis with contrast material was performed. 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 computed tomography (CT) scan rendered on October 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care on December 22, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that you were treated in the emergency room, but the provider dropped the ball on the subsequent care.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care on December 22, 2019. You are asked to pay a $275 copayment for the inpatient hospital care. 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 on December 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot orthotics rendered on January 7, 2020.
You asked the Plan to pay for these services. You say that you received the item from urgent care. The Plan denied your request. The Plan says the services are not covered.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for the foot orthotics rendered on January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the vision services provided on January 10, 2019 and April 2, 2019.You asked the Plan to waive the deductible for the vision services. You say that you were told the provider was in-network.The Plan denied your request. The Plan says that the claim processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $975 deductible for Vision-Non-Medicare covered eyewear out-of-network. The item or service you asked the Plan to waive the deductible for falls within the benefit category,Vision-Non-Medicare covered eyewear out-of-network. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $975 deductible for Vision-Non-Medicare covered eyewear out-of-network. This cost sharing is a contractual obligation that had not been met at the time the vision services was received on January 10, 2019 and April 2, 2019.Therefore, we decided that the Plan does not have to waive the deductible for the vision services provided on January 10, 2019 and April 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for screening mammography provided by an out-of-network provider on November 23, 2019.You asked the Plan to waive the coinsurance for screening mammography. You say that you were not advised that this provider was out-of-network or that you would have cost-sharing.The Plan denied your request. The Plan says the coinsurance amount 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 40% coinsurance for out-of-network screening mammography. The allowed amount of the claim is $180.93, resulting in a coinsurance obligation of $72.37.You have been asked to pay 40% coinsurance for screening mammography. screening mammography falls within the Breast Cancer Screenings (Mammograms) benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance for screening mammography provided by an out-of-network provider on November 23, 2019.Your complaint regarding not being told about the cost-share for this service 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for a Skilled Nursing Facility (SNF) stay provided from
November 15, 2019 to December 14, 2019.
You asked the Plan to pay for SNF stay. You say that you are requesting payment for these services. The Plan
denied your request. The Plan says the denial of payment for these services is correct, because the enrollee was
enrolled in a hospice program for these dates of service and therefore the Plan is not responsible for payment.
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 a Skilled Nursing Facility (SNF) stay provided from
November 15, 2019 to December 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 26,
2019.
You asked the Plan to waive the copayment for the office visit. You say that this was only for toenail cutting.
You say that you are diabetic so there is a $0 copayment. The Plan denied your request. The Plan says the
copayment applied 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 $40 for
each Medicare-covered visit. Covered services include routine foot care for members with certain medical
conditions affecting the lower limbs (such as, but not limited to, diabetes).
You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Podiatry
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 office visit provided on
November 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on December 10, 2019. You asked the Plan to waive the copayment for an ultrasound. You say that you cannot afford the charges. 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 $250 copayment for diagnostic radiology services. You have been asked to pay the allowed amount of $143.26, which is less than the $250 copayment for an ultrasound. An ultrasound 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 an ultrasound provided on December 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a reduction mammoplasty (19318) provided on September
28, 2017.
You asked the Plan to pay for the reduction mammoplasty. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says the claim was received past the allowed
12 month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the reduction mammoplasty was not filed until August 26, 2019. This means
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for a reduction mammoplasty (19318) provided on September 28,
2017.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on May 8, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the services are not supported by the records provided.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on May 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 14, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services. 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 physician's services provided on February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient hospital services rendered from June 11, 2019 to September 20, 2019. You asked the Plan to waive the copayments for these services. You say that you were previously receiving only $15 copayments. The Plan denied your request. The Plan says the copayments were applied 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 $50 copayment per day for outpatient procedures and services in an outpatient hospital. Review of the file shows that you received services at an outpatient hospital on June 11, 2019; July 30, 2019; and September 20, 2019. You have been asked to pay a $50 copayment per day for these services, for a total of $150. These services fall within the outpatient procedures and services in an outpatient hospital 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 copayments for the outpatient hospital services rendered from June 11, 2019 to September 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOtezla tablets.You asked the Plan to pre-approveOtezla tablets. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Otezla tablets are not covered by the enrollee's Medicare Part B benefit.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-approveOtezla tablets.Benefits for Otezla tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing the eye exam and Part B drug rendered to you on December 18, 2019. You asked the Plan to waive the cost sharing these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the cost sharing was applied 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 $50 copayment for in-network Medicare-covered eye exams and a 20% coinsurance for in-network chemotherapy and all over drugs covered under Medicare Part B. Review of the file shows that you received an eye exam on December 18, 2019. You have been asked to pay a $50 copayment for these services. These services fall within the in-network Medicare-covered eye exams 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. The file shows that you received an injection of bevacizumab on December 18, 2019. You have been asked to pay a 20% coinsurance for these services, for a total of $50. These services fall within the in-network Medicare-covered Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing the eye exam and Part B drug rendered to you on December 18, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on November 27, 2019, and November 30, 2019.You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 physical therapy services.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 physical therapy services provided on November 27, 2019, and November 30, 2019.