Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two additional physical therapy sessions.
You asked the Plan to pre-approve the additional sessions. You say that this is medically necessary to continue building strength, and to allow walking on your own. The Plan denied your request. The Plan says 2 of the 4 requested sessions can be approved.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional sessions. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy visits are not medically necessary to continue building strength. You have been educated as per notes by the therapists. 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 additional sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve two additional physical therapy sessions.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the provider depends on the hospital staff to verify eligibility and to obtain the proper authorization. The Plan denied your request. The Plan says the services were not authorized, and therefore, not covered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided on May 3, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0480 provided on May 15, 2019. You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 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 codes 80307 and G0480 are not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition form or medical records stating exactly what was to be tested. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0480 provided on May 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device and appliances provided on September 16, 2019.
You asked the Plan to pay for the pneumatic compression device (E0651) and appliances (E0667). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation did not include an itemized shipping/billing invoice.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The delivery ticket does not have a tracking number and the receipt does not have an itemized list of the supplies received. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and appliances provided on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on October 7, 2019.
You asked the Plan to waive the copayment for the eye exam. You say that you went for a routine eye exam. You say that you should not be responsible for the copayment. 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 per visit for Medicare-covered exams to diagnose and treat diseases of the eye.
You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show that a medical eye exam was performed. 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 eye exam provided on October 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fosaprepitant Dimeglumine, Gemcitabine, Carboplatin, and Palonosetron for the enrollee.
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your request. The Plan says Original Medicare is responsible for the costs associated with clinical trials.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve the drugs as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Fosaprepitant Dimeglumine, Gemcitabine, Carboplatin, and Palonosetron for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services provided to the enrollee on March 29, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the enrollee's plan had ended.
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 Plan has not provided documentation showing that the enrollee's plan had terminated prior to the date of service in question. Without this documentation, the plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services provided to the enrollee on March 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve topical diclofenac 1% gel for the enrollee.
You asked the Plan to pre-approve the gel. You say that this is medically necessary to help with activities of daily living and quality of life. The Plan denied your request. The Plan says the enrollee does not have a pharmacy benefit with the plan.
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 pre-approve topical diclofenac 1% gel for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from December 29,
2018 through December 31, 2018 provided by an out-of-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that all you did was sleep. The
Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you were admitted on December 29, 2018 and discharged on December 31, 2018.
You were asked to pay a $295 copayment per day from December 29, 2018 through December 30, 2018, days
1-2 of your inpatient hospital care. You were discharged on December 31, 2018 and there was no copayment
charge for the day of discharge. Per your contract there is a $295 copayment per day required for days 1-6 for
in-network 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 from December 29, 2018 through December 31, 2018 provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided April 10, 2019 to April 11, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was warranted and supported by clinical documentation in the medical record. The Plan denied your request. The Plan says the criteria for inpatient admission was not met as the enrollee's condition could have been managed at a lower level of care.
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 the enrollee was transferred for specialty consultation and underwent neurology and neurosurgery consultations, additional imaging studies, and neurologic testing. The medical records provided indicate that the admitting physician expected the enrollee's admission to span two midnights. Care provided to the enrollee was observation level. There were no advance interventions or complex medical conditions. She had stable vital signs and no complaints at the time of admission. Inpatient services were not supported by 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 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 April 10, 2019 to April 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have topreapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, Training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on December 16, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency 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 nota network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a health club/gym membership provided from January 3, 2019 to December 3, 2019. You asked the Plan to reimburse you for the health club/gym membership. The Plan denied your request. The Plan says the Flex benefit was removed from your Plan effective January 1, 2019. The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The services at issue in this appeal are gym benefits. You Plan does not offer a Flex benefit effective January 1, 2019. Therefore, we decided that the Plan does not have to reimburse you for a health club/gym membership provided from January 3, 2019 to December 3, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the infusion services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out of network infusion procedure. The Plan denied your request. The Plan says there are insufficient extenuating circumstances to approve the request for out of network care. The Plan says that there are in-network providers who are able to provide the same service.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the infusion services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you were led to believe this provider was covered. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on November 26, 2019 by an out of network (OON) provider.
Your complaint regarding receiving inaccurate information about the network status of this provider 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystourethroscopy provided on December 11, 2019.
You asked the Plan to waive the copayment for the cystourethroscopy. You say that you should not have to pay the surgical center for a procedure that is normally covered under an office copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $210 copayment for surgical services at an in-network ambulatory surgical center. You have been asked to pay a $210 copayment for the cystourethroscopy. The cystourethroscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows the cystourethroscopy was performed at an ambulatory surgical center.
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 cystourethroscopy provided on December 11, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on October 4, 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 procedure codes 95907 and 95886 are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 95907 is nerve conduction studies; 1-2 studies. The
definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when
performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles
studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for
primary procedure).
We find that CPT codes 95907 and 95886 are not supported in the medical record. Specifically, there is no
documentation that 1-2 nerve conduction studies were performed to support code 95907 and no documentation
of a complete needle electromyography to support code 95886. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for the testing services rendered on October 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain 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 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 OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided on January 3, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Lidocaine patch.You asked the Plan to pre-approvea Lidocaine patch. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says a Lidocaine patch is not covered under the enrollee's Medicare Part B benefit.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 pre-approve a Lidocaine patch.Benefits for a Lidocaine patch 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmic ultrasound provided on December 18, 2019.
You asked the Plan to waive the copayment for the ophthalmic ultrasound. You say that you thought you only had copayments. You say that you were not aware you had coinsurance for labs. 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 $30 copayment for Medicare-covered diagnostic radiology services such as an ultrasound and mammography. You have been asked to pay $13.89, which is less than the standard $30 copayment for the ophthalmic ultrasound. The ophthalmic ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 ophthalmic ultrasound provided on December 18, 2019.