Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on January 17, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-faceassessment.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on January 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 24, 2019.You asked the Plan to pay for the laboratory services. The Plan denied yourrequest. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, hasbeen documented. 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 did not pre-approve the servicesat 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 laboratory services provided on July 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora continuous passive motion (CPM) device (E0936).You asked the Plan to pay forthe CPM device. You say that the CPM machine allowed you to achieve normal shoulder/arm range of motion in all directions very quickly.The Plan denied your request. The Plan says the CPM device is only covered if you meet certain conditions. CPM devices used for any diagnosis other than knee replacement surgery are excluded and not covered by Medicare.The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. You have not had total knee replacement surgery.Therefore, we decided that the Plan does not have to pay fora continuous passive motion (CPM) device (E0936).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient laboratory services provided on August 21, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the services could have been provided in network. The Plan also says the services were not urgent or emergent in nature.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 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 forthe outpatient laboratory services provided on August 21, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on April 23, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-faceassessment. The documentation provided reflects that the enrollee 'sent away for a back brace online after phone call'. This does not show that the physician ordered the item.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on April 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 4, 2019 to the enrollee by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.Medicare rulessay 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 forthe medical services provided on October 4, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided June 2, 2019 to June 6, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that services were medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record shows that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. Medically necessary care did span a time period of greater than two 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 been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided June 2, 2019 to June 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelaparoscopic sleeve surgery.You asked the Plan to pre-approvelaparoscopic sleeve surgery. You say that the enrollee has made numerous attempts to lose weight, psychiatric evaluation does not prevent her from proceeding with this procedure, and she has not been non-compliant with medication.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee has been non-compliant with nutritional therapy and psychological evaluation recommends additional evaluation to ensure compliance with the requirements for this surgery program.The Plan follows Medicare rules. Medicare rules say that laparoscopic sleeve surgery is only covered following a pre-operative psychological evaluation and that the mental health professional, surgeon, and enrollee should be in agreement that the enrollee is an appropriate candidate for surgery.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 laparoscopic sleeve surgery. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested surgery. Our physician reviewer found Medicare rules require psychological clearance for this procedure, which is not documented at this time. The enrollee had a psychological evaluation which recommended additional evaluations, however there is no follow-up or final determination provided to support surgery at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of laparoscopic sleeve surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvelaparoscopic sleeve surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcatheter aortic valve replacement (TAVR) for symptomatic aortic insufficiency.You asked the Plan to pre-approve the TAVR procedure. You say that it is felt that this procedure would be the best option for the enrollee and this is the treatment she would like to have.The Plan denied your request. The Plan says Medicare does not cover this procedure for treatment of aortic insufficiency.The Plan must follow Medicare rules. Medicare rules say that TAVR is covered for enrollees participating in clinical registry for the treatment of symptomatic aortic valve stenosis. It can also be covered for a non-FDA-approved indication but only if provided within an approved clinical trial. In this case, there is no evidence of participation in either a clinical registry or trial. In addition, the treatment is not being provided to treat aortic stenosis but for aortic insufficiency.Therefore, we decided that the Plan does not have to pre-approve a transcatheter aortic valve replacement (TAVR) for symptomatic aortic insufficiency.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT Scan (74160) and hernia repair (49654) or pay for the self-administered drugs (A9250) provided on August 19, 2019 through September 12, 2019.
You asked the Plan to waive the copayment for the CT Scan and hernia repair and pay for the self-administered drugs. You say that you would like reconsideration as you have reached your out-of-pocket maximum for the year. The Plan denied your request. The Plan says the copayments for these services were applied correctly per the EOC.
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 $75 copayment for radiological diagnostic services and a $250 copayment for outpatient surgery procedures.
You have been asked to pay a $75 copayment for the CT Scan. The CT Scan 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.
You have been asked to pay an $80 copayment for the hernia repair. The hernia repair falls within the outpatient surgery benefit category. The records indicate, on this date of service you needed to pay the $80 copayment to reach your out-of-pocket maximum. This means you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT Scan (74160) and hernia repair (49654).
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. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist services rendered to you on September 23, 2019 to November 7, 2019.You asked the Plan to waive the copayments for these services. You say that you disagree with the Plan's policies.The Plan denied your request. The Plan says the copayments were applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for specialist services. Review of the file shows that you received specialist services on September 23, 2019; October 3, 2019; and November 7, 2019. You have been asked to pay a $50 copayment per date of service for these services, for a total of $150. These services fall within the specialist 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 copayments forthe specialist services rendered to you on September 23, 2019 to November 7, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology procedures provided on September 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for molecular pathology procedures. You say that this appeal should be approved and paid at the established rate of $2,183.50. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 molecular pathology procedures provided on September 5, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the outpatient surgical services rendered to you on September 23, 2019.
You asked the Plan to waive the deductible for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the deductible was applied correctly.
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 $1,000 yearly deductible for your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the outpatient surgical services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,000 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on September 23, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the outpatient surgical services rendered to you on September 23, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper GI endoscopy (43235) provided on October 25, 2019.
You asked the Plan to waive the copayment for the upper GI endoscopy (43235). You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an upper GI endoscopy in an Ambulatory Surgical Center on the date of service at issue in this appeal. The Plan states the correct copayment has applied per your contract with the Plan.
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 provided in an outpatient hospital setting or ambulatory surgical center. We looked at the file, the Plan's contract and Medicare rules. The file shows you received an upper GI endoscopy on October 25, 2019. You have been asked to pay a $225 copayment for the upper GI endoscopy (43235). The upper GI endoscopy (43235) provided in an Ambulatory Surgical Center falls within the Outpatient hospital 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 upper GI endoscopy (43235) provided on October 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided to the enrollee on October 3, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says there is insufficient evidence to support the services billed.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 physician order and 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. There is no  itemized shipping/billing invoice that indicates the detailed description of the items and there is no patient signature for billed date of service.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided to the enrollee on October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care office visit provided on July 21, 2019.
You asked the Plan to waive the copayment for urgent care visit. You say that you did not see anyone at the
urgent care and should have been seen promptly. The Plan denied your request. The Plan says the copayment
amount you are being charged is 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 $65
copayment for urgent care visit. The record shows that you received an urgent care visit on this date of service,
therefore the urgent care copayment applies to this claim.
You have been asked to pay the allowed amount of $63.58, which is less than $65 copayment for urgent care
visit. Urgent care visit falls within the Urgently Needed 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 an urgent care office visit provided on July 21, 2019.
Your complaint regarding the wait time you experienced at this visit 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CBC and renal function panel provided on September 23, 2019 and September 24, 2019 by an OON provider.
You asked the Plan to pay for the CBC and renal function panel. You say that the services were medically necessary. The Plan denied your request. The Plan says the rendering provider is non-contracted with the enrollee's plan. The Plan also says that prior 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 CBC and renal function panel provided on September 23, 2019 and September 24, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered to you on November 13, 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 the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the provider billed procedure code 99213 (office visit) with diagnosis codes that represent left and right laterality. These diagnosis codes are not appropriate for this type of code. The Plan has confirmed that a new claim is needed from the provider but that you are not behind held liable for these services. Therefore, we decided that the Plan does not have to pay for the office visit rendered to you on November 13, 2019.