Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 29, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you switched dentists because you were unhappy with the first provider, and you feel that this service should be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.
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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on February 19, 2020, and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from August 24, 2020, through August 28, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were to receive home health wound care services, but the nurse did not show, or when she did, she didn't change the bandage or take the brace off, which caused you further inpatient care at another hospital. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 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 show that you received inpatient hospital care provided from August 24, 2020, through August 28, 2020. You are asked to pay a $295 copayment for the inpatient hospital care. Your 2020 EOC states enrollees must pay a $295 copayment per admission for inpatient hospital care. 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 hospital care provided from August 24, 2020, through August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided on August 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for dermatology services. You say that you would like this claim reprocessed and paid. 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 had network providers available who could have provided 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 dermatology services provided on August 24, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for EEG during nonintracranial surgery (eg, carotid surgery) (CPT code 95955-26) provided to the enrollee on October 22, 2020.
You asked the Plan to pay for the service. You say that the service was necessary. The Plan denied your request. The Plan says the service was not necessary. The Plan states the clinical value and effectiveness of an intraoperative EEG in the setting of lumbar spine surgery have not been demonstrated in the peer-reviewed literature. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 pay for the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee underwent non-intracranial surgery. The record does not indicate that the enrollee had any co-morbidities that placed an increased risk of anesthesia such that EEG monitoring would be medically reasonable or necessary. Therefore, the requested EEG monitoring service cannot be recommended. 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 service have not been met. Therefore, we decided that the Plan does not have to pay for EEG during nonintracranial surgery (eg, carotid surgery) (CPT code 95955-26) provided to the enrollee on October 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that because you cannot ambulate you need IRF care. The Plan denied your request. The Plan says IRF care is not medically necessary.
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Finally, there is not a reasonable expectation that you 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additional reimbursement for eyewear purchased on October 23, 2020.
You asked the Plan to pay additional reimbursement for eyewear. You say that you do not believe the remaining cost share is correct. The Plan denied your request. The Plan says based on the claim submitted by your provider for October 23, 2020, payment of $120.00 was issued to the provider per the 2020 eyewear allowance. The remaining balance of $58.90, for services received over the allowance of $120.00 are your responsibility.
Medicare 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 up to $120 toward eyewear. The Plan paid your provider $120 for this eyewear. Any balance after that benefit is your financial responsibility. Therefore, we decided that the Plan does not have to pay additional reimbursement for eyewear purchased on October 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (CPT) L1833), and suspension sleeves (L2397) provided to the enrollee on September 4, 2020.
You asked the Plan to pay for the orthoses and sleeves. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records submitted do not support the enrollee having seen the provider.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. There is no face-to-face encounter provider. Medicare guidance says that Medicare requires that the written order is completed after the face-to-face encounter. If the date of the written order is prior to the date of the face-to-face encounter, the contractor shall deny the claim. Based on this information, we decided that Medicare rules for coverage of the orthoses and sleeves have not been met. Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (CPT) L1833), and suspension sleeves (L2397) provided to the enrollee on September 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 21, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there is no
evidence of a relationship with the enrollee and ordering physician.
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 the services at issue are not supported in the medical record. In this case, there are insufficient
medical records that show signs or symptoms that prompted the testing. Based on this information, we decided
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay
for the lab services provided on July 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy 43235 provided October 22,
2020.
You asked the Plan to waive the copayment for the endoscopy. You say that you were not aware you would be
charged a copayment. The Plan denied your request. The Plan says the copayment as 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 $225
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You have been asked to pay a $225 copayment for the endoscopy. This service 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 copayment for the endoscopy 43235 provided October 22,
2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the computed tomography (CT) scan provided on August 7, 2020.
You asked the Plan to waive the copay for the CT scan. You say that you were under the assumption you did not have a deductible. The Plan denied your request. The Plan says the claim processed correctly
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copay for advanced imaging services at an outpatient hospital or freestanding radiological facility. You have been asked to pay a $40 copay for the CT scan. The CT scan falls within the outpatient diagnostic tests 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 copay for the computed tomography (CT) scan provided on August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for wound dressings and home health visits provided from September 5, 2020, to September 14, 2020.
You asked the Plan to waive the cost-sharing for medical supplies and home health visits. You say that you were told that this would be covered with no extra charge. The Plan denied your request. The Plan says the cost-sharing 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 20% coinsurance for medical supplies and $20 copayment for each home health visit. The allowed amount of the medical supplies is $12.71, resulting in a coinsurance amount of $2.54. There were 5 home health visits, resulting in a total copayment amount of $100. Your total cost-sharing obligation is therefore $102.54. You have been asked to pay 20% coinsurance for medical supplies and $20 copayment for each home health visit. Medical supplies and home health visits fall within the "Durable Medical Equipment (DME) and Related Supplies" and "Home Health Agency Care" benefit categories. 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 cost-sharing for wound dressings and home health visits provided from September 5, 2020, to September 14, 2020. 
Your complaint regarding receiving inaccurate information about the cost-sharing for home health care services is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for transthoracic echocardiography with
contrast (CPT) code C8929) provided on July 28, 2020.
You asked the Plan to waive the cost-sharing for the service. You say that this was a billing error. The Plan
denied your request. The Plan says the claim was processed accordingly with your 2020 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 show that you received the transthoracic echocardiography with contrast (CPT code C8929)
provided on July 28, 2020. At the time of services rendered you had not met your $250 deductible; therefore,
you have been asked to pay $250 for the services to apply to your deductible. Once that was met, you were
asked to pay a $350 copayment for each Medicare-covered outpatient hospital visit. Your 2020 EOC states that
enrollees must pay a $350 copayment for each Medicare-covered outpatient hospital visit, after you meet your
$250 deductible. 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 cost-sharing for transthoracic echocardiography
with contrast (CPT) code C8929) provided on July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride, excluding varnish (D1208) and oral hygiene instructions (D1330) provided on August 20, 2020.
You asked the Plan to pay for the topical application of fluoride and oral hygiene instructions. You say that these services should not have been denied. The Plan denied your request. The Plan says these services are not covered under your benefit plan.
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 topical application of fluoride, excluding varnish (D1208) and oral hygiene instructions (D1330) provided on August 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says it is unclear if the enrollee has the stability for transfer to the IRF.
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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical treated of diverticulitis and an entercutaneous fistula. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Medtronic Guardian 3 continuous glucose monitoring (CGM) supplies.
You asked the Plan to pre-approve the requested CGM supplies. You say that this is medically necessary and should be covered. The Plan denied your request. The Plan says the requested device is not FDA-approved as a therapeutic CGM.
The Plan must follow Medicare rules. Medicare rules say that only CGM devices which meet the definition of a therapeutic CGM are eligible for coverage under Medicare. The requested CGM device is not considered a therapeutic CGM and cannot be covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve the Medtronic Guardian 3 continuous glucose monitoring (CGM) supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another setting.
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical condition does not require intensive physician or nursing supervision in an IRF. You may benefit from additional physical and occupational therapy but the documentation does not reveal that this therapy must be only on an intensive level 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-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance transportation provided on August 10, 2020.
You asked the Plan to pay for the air ambulance transportation. You say that the services were necessary. The Plan denied your request. The Plan says the air ambulance transport was not medically necessary. The Plan states the enrollee was inappropriately transported by air ambulance to a more distant facility at the request of the enrollee's family.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 the air ambulance transportation. Our physician reviewer found the documentation supported that there was a contraindication to non-ambulance transportation due to the severe condition of the enrollee. There was no indication that taking ground ambulance transportation would have posed a threat as the same equipment and services were available and the ground transportation would have placed the enrollee at an appropriate facility sooner. Air ambulance services was not supported in the documentation.
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 air ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance transportation provided on August 10, 2020.