Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the services rendered on August 15, 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 that the claims were submitted with insufficient information.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the claims were not submitted correctly; however, there is no further information or explanation as to why the claims cannot be processed as submitted. Therefore, we decided that the Plan has to pay for the services on August 15, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the chiropractic services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the chiropractic services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are equally qualified in-network Chiropractors available to you that can provide the care and treatment you are requesting.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the chiropractic services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the provider did not discuss the need for the billed supply codes.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at review the file, and Medicare rules. The medical records do not support medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthoses (L1833) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report
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 93010 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 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. We find that CPT code 93010 is not supported in the medical record. Specifically, there is no documentation that EKG interpretation was performed 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 electrocardiogram (EKG) interpretation and report
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusionist services
You asked the Plan to pay for the services provided. You say that the charges are for the perfusionist that set up and operate the heart-lung machine for the enrollee's surgery. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. 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 perfusionist services
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pay for the sling. We decided that the Plan does not have to pay for the knee orthosis and the shoulder orthosis.
You asked the Plan to pay for the knee orthosis, the shoulder orthosis, and the sling. You say that the Plan should pay this claim. The Plan says that there is no documentation of delivery of the orthoses or sling to the enrollee.
We decided that the Plan has to pay for the sling. This supply may be billed separately.
We also decided that the Plan does not have to pay for the knee orthosis and the shoulder orthosis. These items are considered DMEPOS and there is no documentation the enrollee received the orthoses.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on June 26, 2019.
You asked the Plan to waive the copayment for specialist services. You say that you were prescribed the wrong medication and disagree with 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 $40 copayment for services obtained by a specialist. You have been asked to pay a $40 copayment for specialist services. Specialist services fall 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 specialist services provided on June 26, 2019.
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the test supports optimal treatment planning, improves patient outcome, and reduces healthcare costs. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain 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 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 OON services. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 18, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (62321, Q9966, and J1030) provided on September 10, 2018.
You asked the Plan to pay for injections. You say that this should be paid. The Plan denied your request. The Plan says this claim was filed more than a year after the services were provided.
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 injections was not filed until September 27, 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 injections (62321, Q9966, and J1030) provided on September 10, 2018.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the nebulizer with compressorth compressor. You say that you returned the nebulizer in July 2019. The Plan denied your request. The Plan says that the provider confirmed you requested the equipment to be picked up but the driver did not document that the nebulizer with compressor was picked up.
The Plan says you must pay the coinsurance for the nebulizer with compressor. However, you cannot be asked to pay for a nebulizer with compressor that you requested to be picked up. Therefore, we decided that the Plan has to waive the coinsurance for the nebulizer with compressor
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share the transthoracic echocardiography provided on November 6, 2019.
You asked the Plan to waive the cost share the transthoracic echocardiography. You say that you were not told about the cost of the procedure and why it was necessary. You say you would like this bill to be rejected and nullified. 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. Your contract with the Plan says that there is a $500 deductible that applies towards a transthoracic echocardio-graphy and 10% coinsurance for each Medicare-covered outpatient hospital services. The transthoracic echocardiography you asked the Plan to waive the cost share falls within the "Outpatient hospital services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible that applies towards a transthoracic echocardiography and 10% coinsurance for each Medicare-covered outpatient hospital service. See chart below.
This cost sharing is a contractual obligation that had not been met at the time the transthoracic echocardio-graphy was received on November 6, 2019. Therefore, we decided that the Plan does not have to waive the cost share the transthoracic echocardiography provided on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam and to pay for the eye refraction rendered to you on January 6, 2020.
You asked the Plan to waive the copayment for these services. You say that the services should be covered with no charge. The Plan denied your request. The Plan says 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 $35 copayment for each in-network Medicare-covered exam to diagnose and treat diseases and conditions of the eye.
Review of the file shows that you received an eye exam on January 6, 2020. You have been asked to pay a $35 copayment for these services. These services fall within each in-network Medicare-covered exam to diagnose and treat diseases and conditions of the eye 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 rules say that Medicare does not cover routine vision services and eyewear.
The file shows that you also received an eye refraction on January 6, 2020. These services are routine vision services and are not covered by Medicare.
Therefore, we decided that the Plan does not have to waive the copayment for the eye exam and to pay for the eye refraction rendered to you on January 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the gadoxetate disodium injection provided on August 21, 2019.
You asked the Plan to waive the coinsurance for the injection. You say that you were not told there would be an additional charge for the Part B injection. The Plan denied your request. The Plan says that you are responsible for any applicable cost sharing.
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% coinsurance for each Medicare-covered Part B drug. You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Medicare-covered Part B drug 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 the gadoxetate disodium injection provided on August 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on October 25, 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 30140 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 30140 is submucous resection inferior turbinate, partial or complete, any method. We find that CPT code 30140 is not supported in the medical record. Specifically, the operative report does not include documentation or a partial or complete submucuous resection of the inferior turbinate to support code 30140. 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 services rendered on October 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a screening digital breast tomosynthesis (CPT 77063) and a screening mammography (CPT 77067) provided on October 3, 2019.
You asked the Plan to pay for the digital breast tomosynthesis and the mammography services. You say that the records supplied support that the procedures in dispute were performed by the provider. You say that the claim was denied as a duplicate in error. The Plan denied your request. 
The Plan must follow Medicare rules. Medicare rules say that providers must furnish information that allows for a determination as to whether payment is due and the amount of payment. We looked at the file and Medicare rules. The records show that claim number was not an exact duplicate of claim number because the billed amounts were different. However, the records that were furnished do not support that more than one digital breast tomosynthesis and mammogram . One unit for each of these services were paid Based on this information, we decided that Medicare rules for coverage of the claim in
dispute have not been met. Therefore, we decided that the Plan does not have to pay for a screening digital breast tomosynthesis (CPT 77063) and a screening mammography (CPT 77067) provided on October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on November 8, 2019.
You asked the Plan to waive the deductible for the office visit. You say that you had no issues with your eye sight. You say that your eye exam should be covered. The Plan denied your request. The Plan says the deductible applied 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 your in-network deductible is $250, which applies to all items and services except those specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before we will pay our share for your covered in-network medical services. Specialist services are not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $250 in-network deductible applies to specialist office visits. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on November 8, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on November 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve attendant control, push handles, an expandable controller and harness, electronic connection to control power tilt, a foot plate, Roho Smartcheck system, and a seat back cushion.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the items are not covered.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The requested expandable control with harness and electronic connection serve the same purpose as the approved power options. The approved power options come with their own switches. The requested footplate is already included in the power tilt and recline. The requested seatback cushion is already included in the approved hardware.
The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The requested push handles and Roho Smartcheck system do not service a purpose that is primarily medical in nature and are therefore not covered.
The rules say that if an attendant control (E2331) is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered.
The requested attendant control is not covered because it is being requested in additional to the approved beneficiary-operated drive control system. The file shows that you have adequate strength to operate the approved system.
Therefore, we decided that the Plan does not have to pre-approve attendant control, push handles, an expandable controller and harness, electronic connection to control power tilt, a foot plate, Roho Smartcheck system, and a seat back cushion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental core buildup for teeth #6, 8, 9, and 11.
You asked the Plan to pre-approve the core buildup. You say that you have extreme sensitivity to hot and cold. The Plan denied your request. The Plan says the service is not a covered benefit.
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 pre-approve a dental core buildup for teeth #6, 8, 9, and 11.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve myocardial perfusion imaging for the enrollee.
You asked the Plan to pre-approve the imaging. You say that the enrollee has limited functional capacity and is complaining of chest pain. The Plan denied your request. The Plan says that a treadmill test might show the doctor what is needed in order to treat the enrollee.
The Plan must follow Medicare rules. Medicare rules say that cardiovascular nuclear imaging is covered under certain circumstances and 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 the imaging. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found myocardial perfusion imaging is requested to evaluate for myocardial ischemia in this enrollee with known coronary artery disease, status post coronary artery bypass grafting, who complains of
episodes of substernal chest pressure associated with shortness of breath. The records indicate that there was evidence of mild ischemia on dobutamine echocardiogram performed January 25, 2019, and that a recent electrocardiogram was abnormal - demonstrating antero lateral STT wave abnormalities. The enrollee's other medical problems include chronic obstructive pulmonary disease, hypertension, pre-diabetes, hyperlipidemia, and peripheral vascular disease, status post multiple stents and revascularization with recent leg pain related to left SFA (superficial femoral artery) stent placement on February 28, 2020. It is noted that the enrollee has a decreased functional capacity with marked limitation in ability to ambulate associated with her noted medical conditions. The documentation provided indicates that the Medicare coverage rules for the requested myocardial perfusion imaging have been met. 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 imaging have been met. Therefore, we decided that the Plan has to pre-approve myocardial perfusion imaging for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.