Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided from January 10, 2019 to January 16, 2019.
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for outpatient rehabilitation services for inpatient stay: covered services received in a hospital or SNF during a non-covered inpatient stay. The enrollee received outpatient rehabilitation services from January 10, 2019 to January 16, 2019 for a total of 5 services. Therefore, the enrollee is responsible to pay a $40 copayment per each outpatient rehabilitation service. The total amount the enrollee owes is $40 (copayment) x 5 (outpatient rehabilitation services) = $200. The enrollee has been asked to pay the total copayment amount of $200 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the inpatient stay: covered services received in a hospital or SNF during a non-covered inpatient stay benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided from January 10, 2019 to January 16, 2019.
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-of-network provider on January 10, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 on January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on January
7, 2020.
You asked the Plan to waive the copayment for the medical eye exam. You say that you had a routine eye exam
and there was no diagnosis. 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 $40
copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye, including an annual
glaucoma screening for members at high risk.
You have been asked to pay a $40 copayment for the medical eye exam. The medical eye exam falls within the
"Vision care" benefit category. The medical record shows diagnoses of age-related cataracts and open angle
with borderline findings and low glaucoma risk in both eyes.
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 medical eye exam provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on February 10, 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 covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are
statutorily excluded.
The provider submitted a claim for procedure code 99190 (special pump services). This code has a status
indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.
Therefore, we decided that the Plan does not have to pay for the special pump services rendered on February
10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
You asked the Plan to pre-approve the Durolane. You say that the drug in dispute is medically necessary. The Plan denied your request. The Plan says their preferred viscosupplements are Orthovisc and Monovisc. The Plan says that the documentation provided does not support the medical necessity of a step therapy exception.
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 the Durolane. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a history of right knee pain due to osteoarthritis. A left knee arthroscopy documented arthritis and degenerative medial and lateral meniscus tears. The enrollee has tried conservative nonpharmacologic treatments such as education, strengthening and range of motion exercises. The prescriber also states the enrollee has had previous treatment, contraindication or intolerance to simple analgesic therapy and intraarticular corticosteroids. Our physician reviewer found that the records do not demonstrate that the enrollee has had previous treatment, contraindication or intolerance to Orthovisc and Monovisc.
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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine provided on February 21, 2020.
You asked the Plan to pay for the shingles vaccine. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a shingles vaccine is not covered under your Medicare Part B benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on February 21, 2020.
Benefits for the shingles vaccine 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forchemotherapy infusions provided on April 3, 2019 and April 24, 2019.You asked the Plan to waive the coinsurance forchemotherapy infusions.You say that you 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 allcost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received a chemotherapy infusion on April 3, 2019. The total allowed amount is $9,889.70 and 20% of that is $1,977.94. You received a chemotherapy infusion on April 24, 2019. Therefore, you are responsible to pay $477.56, which is less than the 20% coinsurance amount. The total amount you owe is: $2,455.50. You have been asked to pay the total coinsurance amount of $2,455.50 for chemotherapy infusions. Chemotherapy infusions fall within the Medicare Part B prescription 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 coinsurance forchemotherapy infusions provided on April 3, 2019 and April 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient mental health care from July 31, 2018 through August 3, 2018.
You asked the Plan to waive the copayment for inpatient mental health care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2018 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 shows that you were admitted on July 31, 2018 and discharged on August 3, 2018. You were asked to pay a $200 copayment per day from July 31, 2018 through August 2, 2018, days 1-3 of your inpatient mental health care. You were discharged on August 3, 2018 and there was no copayment charge for the day of discharge. Per your contract there is a $200 copayment per day required for days 1-5. 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 mental health care from July 31, 2018 through August 3, 2018.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the surgical services rendered on March 14, 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 that code 64999 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 64999 is unlisted procedure, nervous system.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 these services. Our reviewers says that the submitted records support the billing of code 64999. Our physician reviewer found the documentation does support the code 64999, unlisted procedure. Per Medicare submission-errors-solutions, when billing a service or procedure, select the CPT or HCPCS code that accurately identifies the service or procedure performed. If no such code exists, report the service or procedure using the appropriate unlisted procedure not Otherwise Classified (NOC) code. The records support the use of code 64999.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met.Therefore, we decided that the Plan has to pay for the surgical services rendered on March 14, 2020.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.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 that the enrollee was admitted to an acute care hospital with recurrent pneumonia and acute-on-chronic hypoxemic respiratory failure. Antibiotics are being administered. On July 3, 2020,a computed tomography (CT) scan was pending to evaluate for a possible lung abscess. The enrollee has been requiring high-flow nasal cannula oxygen and BiPAP. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care.The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on February 14, 2020.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of
"C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as
"inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the
Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger
(99190) provided on February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you assumed this provider was in-network with the Plan. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 March 13, 2020 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for a colonoscopy (45378) and esophagogastroduodenoscopy (43239) provided on January 24, 2020.
You asked the Plan to pay for a colonoscopy and esophagogastroduodenoscopy. You say that this should be covered. The Plan denied your request. The Plan says coverage of these services is the responsibility of 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 a colonoscopy (45378) and esophagogastroduodenoscopy (43239) provided on January 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 27, 2019.You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. We looked at the file and Medicare rules. The testing in question was billed with 27 CPT codes. Per Medicare rules, the testing should have been billed with one CPT code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.Therefore, we decided that the Plan does not have to pay for the lab services provided on September 27, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approve SNF services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee does not require skilled medical treatment daily.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and physician services provided on January 20, 2020 by an out of network (OON) provider.You asked the Plan to pay for an office visit and physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these 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 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 an office visit and physician services provided on January 20, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a respiratory virus panel by PCR with 12-25 targets provided in the outpatient hospital setting on January 4, 2020 coded as 87633.
You asked the Plan to pay for the respiratory virus by PCR testing panel. You say that this was a medically necessary test necessary to diagnose the patient's condition and should be covered. The Plan denied your request. The Plan says this claim was denied as not meeting LCD criteria, but it was found on appeal that this is not separately payable since this was provided to a hospital inpatient.
Please note that Maximus disregarded the Plan's rationale about inpatient status as there is no evidence that this enrollee was an inpatient and all services were billed on an outpatient claim.
The Plan must follow Medicare rules. Medicare rules say that multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. This testing was for 12-25 pathogens and is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for a respiratory virus panel by PCR with 12-25 targets provided in the outpatient hospital setting on January 4, 2020 coded as 87633.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the declotting procedure of the implanted device provided on March 10, 2020.
You asked the Plan to waive the copayment for the declotting procedure of the implanted device. You say that you had a port draw and flush, not surgery. You say that your cost should be $150. 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 $200 for each in-network, Medicare covered outpatient hospital facility visit. You have been asked to pay a $200 copayment for the declotting procedure of the implanted device. The declotting procedure of the implanted device falls within the "Outpatient hospital services" benefit category. The declotting procedure of the implanted device is considered a surgical procedure that was provided by the hospital. 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 declotting procedure of the implanted device provided on March 10, 2020.