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

We decided that the Plan does not have to pay forphysician services provided on July 30, 2019, October 28, 2019 and January 17, 2020.You asked the Plan to pay forthe physician services. You say that this doctor wants to see you every fourmonths so you want to submit the claims.The Plan denied your request. The Plan says this physician opted of Medicare therefore the claimsare ineligible for payment.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by aprovider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay forphysician services provided on July 30, 2019, October 28, 2019,and January 17, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99283) provided on August 10, 2020.
You asked the Plan to pay for an emergency room visit. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with an appropriate primary diagnosis.
The Plan must follow Medicare rules. Medicare rules say that when coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug (T36-T50). We looked at the file and Medicare rules. The billed primary diagnosis, T36.4X5A, should be billed after an appropriate code for the nature of the adverse effect and is therefore not an appropriate primary diagnosis. Based on this information, we decided that Medicare rules for coverage of an emergency room visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99283) provided on August 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance services provided on August 13, 2020.You asked the Plan to waive the copayment forthe ambulance services. You say that you should not be charged a copaymentfor the transport.The Plan denied your request. The Plan says you were charged this cost sharing 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 $250 copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $250 for these services. 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 forthe ambulance services provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (64494) provided on June 24, 2020.
You asked the Plan to pay for injections. You say that this was billed correctly. The Plan denied your request. The Plan says the billed units exceed the MUE for this code.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 64494 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (64494) provided on June 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient surgery services rendered on August 6, 2020.You asked the Plan to waive the copayment forthese services. You say that you shouldn't be responsible because you didn't choose to go to the hospital.The Plan denied your request. The Plan says the copayment 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 $300 copayment for same day outpatientsurgery at an outpatient hospital facility. Review of the file shows that you received outpatient surgical services in the form of an upper endoscopy on August 6, 2020. You have been asked to pay a $300 copayment for these services. These services fall within the same day outpatient surgery at an outpatient hospital facility 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 forthe outpatient surgery services rendered on August 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the requested semi-electric hospital bed is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a semi-electric hospital bed.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 a semi-electric hospital bed. Our reviewer says that the enrollee does not meet criteria for a semi-electric hospital bed. Our physician reviewer found the documentation does not clearly reveal that the enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for an immediate or frequent change in body position or special attachments that cannot be fixed on an ordinary bed. The head of the bed does not need to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. The request for a semi-electric hospital bed is not medically necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments foremergency room visits provided from July 23, 2020, to July 26, 2020.You asked the Plan to waive the copayments foremergency room visits. You say that these visits were all concerning the same problem, so you do not feel you should have to pay these copayments.The Plan denied your request. The Plan says the copayment amounts you are being charged are 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 $90 copayment for each emergency room visit. There were 4 visits, resulting in a total copayment amount of $360.You have been asked to pay $90 copayment for each emergency room visit. Emergency room visits fall within the Emergency Care 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 foremergency room visits provided from July 23, 2020, to July 26, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction procedure (92015) performed on August 10, 2020.
You asked the Plan to pay for an eye refraction procedure. You say that it is essential that your medical team have access to all your medical records without having to order copies from outside sources. The Plan denied your request. The Plan says rules for payment have not been met.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when obtained through its contracted vision care provider. We looked at the file and the Plan's rules. The provider in this case is not the Plan-contracted vision care provider. Based on this information, we decided that the Plan's rules for coverage of an eye refraction procedure have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction procedure (92015) performed on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second pair of eyeglasses.
You asked the Plan to pre-approve the second pair of eyeglasses. The Plan denied your request. The Plan says a
second pair of eyeglasses is not covered by Medicare or offered as a supplemental benefit by the Plan.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services every calendar year.
We looked at the file and the Plan's rules. The file shows that the Plan provides coverage for one pair of
standard eyeglasses (prescription lenses, frames, or a combination of lenses and frames) or contact lenses every
calendar year. Therefore, we decided that the Plan does not have to pre-approve a second pair of eyeglasses.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to hold you harmless forthe noncovered items/services provided during an outpatient hospital stay from August 6, 2020, to August 7, 2020.You asked the Plan to hold you harmless forthe noncovered items/services. You say that you do not understand why you are being billed this amount.The Plan denied your request. The Plan says that the claim was billed on an invalid Type of Bill.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. In this case, we find that the documentation provided by the Plan is not sufficient to support the denial. The Plan's denial rationale indicates that the network provider used an invalid Type of Bill. Billing issues with network providers must be addressed between the Plan and its provider. The codes billed on this claim are generally used to describe self-administered drugs provided in the outpatient setting. However, in order to uphold a denial for this reason, Maximus must be given a copy of the itemized bill from the hospital. Without the ability to verify that the drugs billed under these codes are self-administered, the denial is not supported.Therefore, we decided that the Plan has to hold you harmless forthe noncovered items/services provided during an outpatient hospital stay from August 6, 2020, to August 7, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospitalinpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational therapy services but you do not require an intensive inpatient rehabilitation therapy program. You require the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on July 27, 2020 by an OON provider.
You asked the Plan to pay for the resin-based composite. You say that your regular dentist was not able to treat you, and you were treated by this OON provider. You also say that you should not have to pay for this service because you were told it would be covered in error. The Plan denied your request. The Plan says this service was rendered by an OON provider. The Plan also says that you have to visit an in-network provider to use your Plan benefits.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on July 27, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible foran electrocardiogram (93000) performed on August 21, 2020.You asked the Plan to waive the deductible foran electrocardiogram. You say that you were advised to send records to have this procedure processed for payment.The Plan denied your request. The Plan says the correct cost-sharing was applied.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 for advanced imaging services. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for advanced imaging services. This cost sharing is a contractual obligation that had not been met at the time an electrocardiogram was received on August 21, 2020.Therefore, we decided that the Plan does not have to waive the deductible foran electrocardiogram (93000) performed on August 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs doesnot require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services and coinsurance for an injectionprovided by a participating provider on September 21, 2020.You asked the Plan to waive the copayment for specialist services and coinsurance for an injection. You say that you do not agree with these charges.The Plan denied your request. The Plan says the correct copayment and coinsurance has been applied.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 $45 copayment for physician/practitioner services/in-network/provider and professional services/specialist's and a 20% coinsurance for Medicare Part B prescription drugs/in-network/specialist's. You have been asked to pay a $45 copayment for specialist services and a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $1,830. The amount you are being asked to pay for an injection is $366 ($1,830 x 20% = $366). The total amount you are being asked to pay is $411 ($366 + $45 = $411). Specialist services falls within the physician/practitioner services/in-network/provider and professional services/specialist's and an injection falls within the Medicare Part B prescription drugs/in-network/specialist's benefitcategory. 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 and coinsurance forspecialist services and an injection provided by a participating provider on September 21, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 17, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for hearing aids provided on June 18, 2020.
You asked the Plan to pay for the hearing aids. You say that you received the hearing aids from an in-network provider. You say that this provider advised you that the hearing aids would be covered by the Plan. You say that it never occurred to you that the Plan would require you get hearing aids from a provider who is not affiliated with the in-network audiologist. The Plan denied your request. The Plan says that the provider who supplied the hearing aids is not part of their vendor network.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the hearing aids by a contract provider. The file does not show that the Plan provided notice that the hearing aids would not be covered. There is coverage for hearing aids under some conditions, and the hearing aids you received were ordered by an in-network provider. It was reasonable for you to assume that the in-network audiologist would supply you with hearing aids from a covered vendor or notify you of non-coverage. Under Medicare rules, this means the hearing aids is considered approved by the Plan. Therefore, we decided that the Plan has to pay for hearing aids provided on June 18, 2020.