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

We decided that the Plan has to pay for the suture removal you received on December 15, 2020.

You asked the Plan to pay for the suture removal. You say that you went to the clinic because it would be cheaper than the emergency room. The Plan denied your request. The Plan says that this is not a covered service.

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 provided the suture removal by a contract provider. The file does not show that the Plan provided notice that the suture removal would not be covered. Under Medicare rules, this means the suture removal is considered approved by the Plan. You received the services with the reasonable expectation they would be covered under your plan. Therefore, we decided that the Plan has to pay for the suture removal you received on December 15, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry services provided on January 18, 2021.

You asked the Plan to waive the copayment for the podiatry services. You say that you do not have a copayment for routine podiatry visits. The Plan denied your request. The Plan says the record shows this was not a routine podiatry visit therefore you were charged this copayment 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 $45 copayment for Podiatry Services. 

You have been asked to pay a $45 copayment for the podiatry services. The podiatry visit falls within the Podiatry Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the podiatry services provided on January 18, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on February 26, 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 had network providers available who could have provided 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 services provided to the enrollee by an out-of-network provider on February 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (D7140) received December 15, 2020.

You asked the Plan to pay for the extraction. You say that you thought this would be covered by your plan. The Plan denied your request. The Plan says the requested service is not covered under your supplemental 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 pay for the extraction, erupted tooth or exposed root (D7140) received December 15, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the initial hospital care provided on November 7, 2020.
You asked the Plan to pay for the services provided. You say that the enrollee was admitted to the hospital for ongoing treatment. The Plan denied your request. The Plan says that the procedure has been billed and allowed the maximum number of times.
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 file does not contain substantial information explaining why the code was denied. There are insufficient records to show the code was previously billed and paid for the date of service at issue. Therefore, we decided that the Plan has to pay for the initial hospital care provided on November 7, 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 the enrollee meets guidelines for long term acute care. The Plan denied your request. The Plan says the enrollee's needs are met in the current setting.

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 the enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on December 2, 2020.

You asked the Plan to pay for the self-administered drugs. You say that you believe this service should be covered. The Plan denied your request. The Plan says self-administered drugs are not covered under Part B of Original Medicare.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on December 2, 2020.

Benefits for the self-administered drugs 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: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve intensity modulated radiation therapy (IMRT) for the enrollee.
You asked the Plan to pre-approve the radiation therapy. You say that this would provide sustained control of the lesion. The Plan denied your request. The Plan says that this is not reasonable and necessary under Medicare guidelines.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pre-approve the radiation therapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found there is justification for the need for IMRT, as there is not a safe way to treat the enrollee to doses in excess of 66-70 Gy without IMRT as non-IMRT plans deliver excessive dose to the bowel - which is seen in the comparison plan. The dose used for this patient is relatively high (plan for 7 weeks), and the IMRT plan results in marked reduction in bowel exposure, such that it is plausible that IMRT could be of benefit in this enrollee in lowering the toxicity risk to the bowel, particularly if concurrent chemotherapy is to be given. Conceding that the liver lesion complicates this enrollee's treatment plan, IMRT seems to be medically necessary (particularly given the effort to work-up the liver lesion). Justification for IMRT is provided in this case. As such, the need for IMRT is established and plausible and would be furnished in accordance with accepted standards of medical practice. 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 radiation therapy have been met. Therefore, we decided that the Plan has to pre-approve intensity modulated radiation therapy (IMRT) 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lumbar injection provided on October 7, 2020.

You asked the Plan to waive the copayment for the lumbar injection. You submitted your bill for review. 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 $295 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. 

You have been asked to pay a $295 copayment for the lumbar injection. The lumbar injection falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the lumbar injection provided on October 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 9, 2020, through November 10, 2020.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says based upon records available, the care delivered is consistent with an observation stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the ED with weakness, vomiting, cough for four days. The enrollee's wife has COVID-19. The enrollee denied shortness of breath, abdominal pain, or diarrhea. The enrollee was unable to take oral home meds due to vomiting. The enrollee's vitals were T97, BP153/76, P90, R18, 96%RA. PE unremarkable except for lethargy. The last vomit was the day prior. The enrollee's glucose 61, BUN 28, Covid positive. CXR no acute process. The enrollee was treated with fluids with improvement in symptoms. The enrollee's records suggested low risk needs as the enrollee was not eating and did not require insulin therapy at the time of admission and required fluids until symptoms resolved which was not expected to require hospitalization that would likely cross 2 midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 9, 2020, through November 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hip x-ray (73501) provided to the enrollee on August 17, 2020 and billed under Claim A.

You asked the Plan to pay for Claim A. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan stated that Claim A denied because the plan had already paid for this service under another claim. The Plan states the NPI website shows that both providers are listed as diagnostic radiology specialists and both providers work within the same professional practice or group. The Plan states the correct billing of this service needed to include modifier -59 to establish a separate and distinct service was provided.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met.

Therefore, we decided that the Plan does not have to pay for a hip x-ray (73501) provided to the enrollee on August 17, 2020 and billed under Claim A.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the monitoring feature/device (A9279) provided on December 3, 2020.
You asked the Plan to pay for the monitoring feature/device. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code A9279 has a status indicator of I and is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code A9279 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code A9279 has a status indicator of I. This means that CPT code A9279 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the monitoring feature/device have not been met. Therefore, we decided that the Plan does not have to pay for the monitoring feature/device (A9279) provided on December 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic testing supplies (A4259, A4253, A4256, A4258) provided to the enrollee on May 20, 2020.

You asked the Plan to pay for the diabetic testing supplies. You say that the documentation supports necessity for the denied codes. The Plan denied your request. The Plan says the diabetic supplies may be required, but there is no exception to the plan's exclusivity coverage.

The Plan must follow Medicare rules. Medicare rules say that diabetes testing supplies are covered when they are made by the plan's exclusive diabetic supplies.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have a valid reason to not use use the plan's exclusive diabetic supplies. Based on this information, we decided that Medicare rules for coverage of the diabetic testing supplies have not been met. Therefore, we decided that the Plan does not have to pay for the diabetic testing supplies (A4259, A4253, A4256, A4258) provided to the enrollee on May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings for teeth # 2, 4, 5, 6, 7, 10, 11, 14, and 15 provided from December 8, 2020, to December 29, 2020.

You asked the Plan to pay for the dental services. You say that you had radiation treatments 2 years ago. You say that your teeth have begun to deteriorate. You say that you were unaware that the necessary services would not be covered. You say that these services would have been covered under your Medicaid benefit. You also say that you are unable to cover these services on your own. The Plan denied your request. The Plan says 2 fillings are covered per calendar year. The Plan says that the frequency limit has been exceeded.

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 and fillings are listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a filling for tooth # 13 that you received on October 2, 2020, and a filling for tooth # 12 that you received on December 8, 2020. Therefore, we decided that the Plan does not have to pay for the fillings for teeth # 2, 4, 5, 6, 7, 10, 11, 14, and 15 provided from December 8, 2020, to December 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray provided to the enrollee on July 27, 2020 and billed under Claim A.
You asked the Plan to pay for Claim A. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan stated that Claim A was denied because the Plan had already paid for this service under another claim. The Plan states the NPI website shows that both providers are listed as diagnostic radiology specialists and both providers work within the same professional practice or group. The Plan states the correct billing of this service needed to include modifier -59 to establish a separate and distinct service was provided. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met.
Therefore, we decided that the Plan does not have to pay for a chest x-ray provided to the enrollee on July 27, 2020 and billed under Claim A.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound you received on October 6, 2020.

You asked the Plan to waive the cost share. The Plan denied your request. The Plan says you are responsible for the copayment.

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 $160 copayment for each Medicare-covered radiological diagnostic service. 

Review of the file shows that had an ultrasound on October 6, 2020. Per your contract with the Plan, there is a $160 copayment for an ultrasound. This cost sharing is a contractual obligation that you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $133.40. Given that the allowed amount was less than the $160 copayment, you have been asked to pay $133.40 for the ultrasound. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound you received on October 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an online fitness class on December 31, 2020.

You asked the Plan to pay for an online fitness class. You say that you could not attend in person due to COVID-19 and you would like the Plan to pay. The Plan denied your request. The Plan says this is not a covered benefit.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

The Plan's rules for coverage of gym benefits have not been met because online fitness classes are not a covered benefit. Therefore, we decided that the Plan does not have to pay for an online fitness class on December 31, 2020.