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

We decided that the Plan does not have to pay forskilled nursing services provided on September 16, 2019 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that your provider is contracted with the rehabilitation center. You say that you would like to collect the money rightfully due to you.The Plan denied your request. The Plan says no prior authorization was 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 forskilled nursing services provided on September 16, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for a colonoscopy provided on December 3, 2018. You asked the Plan to waive the copayment for a colonoscopy. You say that you disagree with the charges because the results were normal. The Plan denied your request. The Plan says that you were charged the correct copayment amount due to your personal history of polyps. The Plan must follow Medicare rules. Medicare covers 1 screening colonoscopy every 2 years or 1 barium enema every 2 years for people with high risk of colon cancer. An individual with a person history of adenomatous polyps meets the definition of "person with high risk of colon cancer" under Medicare rules. There is no evidence that this colonoscopy was ordered for diagnostic purposes or that any polyps were removed during this colonoscopy. The Plan did not submit any medical records from the ordering provider showing what type of colonoscopy was ordered or the reason it was ordered. A person with a personal history of polyps is considered to be at high risk of colon cancer. People at a high risk of colon cancer are eligible for screening colonoscopies under Medicare rules and these screening colonoscopies are covered at a greater frequency for those at high risk. No evidence has been submitted to show that your screening colonoscopy benefit was exhausted on this date of service. Based on the documentation submitted by the health plan, we find that you received a screening colonoscopy. Medicare rules say that, if a preventive service is covered with $0 cost-sharing under Original Medicare, the health plan cannot impose cost-sharing for the service when it is provided by in-network providers. Priority Health must follow this rule. 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 no coinsurance, copayment or deductible for colorectal cancer screening. The Plan says you must pay a $275 copayment for a colonoscopy. Based on the Plan contract, however, you cannot be asked to pay for a screening colonoscopy. Therefore, we decided that the Plan has to waive the copayment for a colonoscopy provided on December 3, 2018. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 14, 2019 by an out of network (OON) provider. 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 were rendered by a non-participating provider without prior authorization. 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 October 14, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have provide additional reimbursement for the Tracheostoma filters provided on November 19, 2019.
You asked the Plan provide additional reimbursement for the filters. You say that you would like additional reimbursement. The Plan denied your request. The Plan says that you were reimbursed up to the allowed amount.
The Plan must follow Medicare rules. Medicare requires health plans to cover only what Original Medicare covers. Original Medicare pays for durable medical equipment based on a fee schedule. Reimbursement in excess of the fee schedule amount is not paid by Original Medicare, and cannot be required of the Plan. Therefore, we decided that the Plan does not have provide additional reimbursement for the Tracheostoma filters provided on November 19, 2019.
Please note: You paid more than the fee schedule amount out of pocket to this supplier. MAXIMUS does not have jurisdiction to make decisions regarding a purchase agreement between you and a third party not affiliated with the enrollee's health plan. You may wish to contact the supplier directly with questions or concerns.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for extracapsular cataract removal provided by The Outpatient Surgery Center on November 27, 2019.
You asked the Plan to waive the coinsurance for extracapsular cataract removal. You say that the provider is in-network and 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 all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 30% coinsurance for out-of-network outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received extracapsular cataract removal from an out-of-network provider on November 27, 2019. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The allowed amount is $886.93 and 30% of that is $266.08. You have been asked to pay the total coinsurance amount of $266.08 for extracapsular cataract removal. Extracapsular cataract removal falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for extracapsular cataract removal provided by The Outpatient Surgery Center on November 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing (CPT 95999) provided on June 18, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service. 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 95999 is "Unlisted neurological or neuromuscular diagnostic procedure". We find that CPT code 95999 is not supported in the medical record. Specifically, train of four testing is not an unlisted procedure. There is a more appropriate CPT code for train of four testing. Additionally, train of four testing is a bundled procedure and is not separately payable. Based on this information, we decided that Medicare rules for coverage of CPT 95999 have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing (CPT 95999) provided on June 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and hearing tests provided on November 11, 2019.
You asked the Plan to waive the copayment for the office visit and hearing tests. You say that it costs less when the doctor is out-of-network. You say that you were not informed there would be separate copayments. The Plan denied your request. The Plan says the copayments 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 each Medicare covered in-network specialist visit and a $50 copayment for each in-network, Medicare-covered exam to diagnose and treat hearing and balance issues. You have been asked to pay a $50 copayment for the office visit and a $50 copayment for the hearing tests. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The hearing tests fall within the "Hearing 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 and hearing tests provided on November 11, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the positron emission tomography (PET) scan rendered on November 1, 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 diagnosis is not supported. The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 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 reviewer says that the services were medically necessary. Our physician reviewer found the enrollee has occult malignancy and the PET/CT was requested for subsequent strategy. The Medicare rules allow PET/CT as a subsequent strategy. The enrollee does not have a non-covered indication. The PET scan was reasonable and medically 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 these services have been met. Therefore, we decided that the Plan has to pay for the positron emission tomography (PET) scan rendered on November 1, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar (E0241). You asked the Plan to pre-approve a grab bar. You say that the item is necessary for you to be able to shower safely. The Plan denied your request. The Plan says the requested item is considered a self-help device and is not primarily medical in nature. Therefore, coverage criteria has not been met. The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a grab bar (E0241).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response, treatment no transport (A0998) provided December 28, 2019. You asked the Plan to pay for the ambulance response, treatment no transport. You say that A0998 GY should be denied as PR-96: non-covered with full amount places as patient responsibility. The Plan denied your request. The Plan says this service is not covered. 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 December 28, 2019. 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 for the ambulance response, treatment no transport (A0998) provided December 28, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on October 9, 2019. You asked the Plan to waive the copayment for a colonoscopy. You say that you disagree with the charges because this was a colonoscopy screening. 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 $450 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical center. The medical records show that you had polyps removed during a colonoscopy on October 9, 2019. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $450 copayment. You have been asked to pay a $450 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical center 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 a colonoscopy provided on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 28, 2019. You asked the Plan to pay for the pump assembly operation. You say that it takes 30 minutes to set up the machine and the perfusionist is required to be in the operating room for the duration of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor. The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF care.
You asked the Plan to pre-approve continued SNF care. You say that you would like permission for the enrollee to continue treatment at the SNF. The Plan denied your request. The Plan says SNF admission is not a covered service under the Medicare plan.
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 continued SNF care. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe CYP gene panel provided to the enrollee on October 17, 2019You asked the Plan to pay forthe testing. You say that this should be paid for.The Plan denied your request. The Plan says this was not coded correctly.The Plan must follow Medicare rules. Medicare rules say that CYP gene panels should be coded with CPT 81479, and are not covered. The services should have been coded with CPT 81479. They are also not covered. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plan does not have to pay forthe CYP gene panel provided to the enrollee on October 17, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Typhoid vaccination provided on November 5, 2019.You asked the Plan to pay forthese services. You say that your vaccines have always been covered in the past.The Plan denied your request. The Plan says that this is not covered under Medicare Part A or Part B.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to these services.Therefore, we decided that the Plan does not have to pay forthe Typhoid vaccination provided on November 5, 2019.Benefits for these servicesmay 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 copayment for physical therapy provided on November
11, 2019.
You asked the Plan to waive the copayment for physical therapy. You say that they did nothing for you. You
say that you shouldn't have to pay. 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 a $40
copayment for each therapy visit.
You have been asked to pay a $40 copayment for physical therapy. Physical therapy falls within the
"Outpatient rehabilitation 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
physical therapy provided on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee arthroplasty provided on October 23, 2019 to October 24, 2019 by an out of network (OON) provider. You asked the Plan to pay for a knee arthroplasty. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was 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 a knee arthroplasty provided on October 23, 2019 to October 24, 2019 by an out of network (OON) provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis services provided to the enrollee on January 11, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says there was no authorization for 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 dialysis services provided to the enrollee on January 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe catheter placement provided on November 2, 2018.You asked the Plan to waive the coinsurance forthe catheter placement. You say that there was no reason to use an out-of-network doctor. You say that the charges should be reversed.The Plandenied your request. The Plan says the coinsurance 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 25% as your portion of the covered charges for each surgery or observation room service in an in-network outpatient hospital. You have been asked to pay $845.54, which is 25% of the allowed amount for the catheter placement. The allowed amount is $3,382.17 (25% x $3,382.17 = $845.54). The catheter placement falls within the "Outpatient hospital services" benefit category. The records show that you were charged the in-network rate. 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 forthe catheter placement provided on November 2, 2018.