Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you needed help from paramedics. You say that your family called the ambulance because they were scared since you were unresponsive. You stated that you cannot pay for the bill and that the Plan should cover it. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 21, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for CPAP Device provided from March 7, 2018 through October 7, 2019 by an out-of-network provider.You asked the Plan to pay for the CPAP device. You say that you went to the provider knowing they were an out-of-network provider, but you made an appointment with this provider because the provider would do a sleep study at your home.The Plan denied your request. The Plan says there was no prior authorization obtained, and no Plan direction given to you to see a physician for a sleep study.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.You went knowing she was an out-of-network provider. The medical records provided  determine that you do qualify for a CPAP machine and supplies. However, you still needed to see an in-network provider and receive prior authorization. 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 forCPAP Device provided from March 7, 2018 through October 7, 2019 by an out-of-network provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepolysomnography (95810).You asked the Plan to pre-approvethe polysomnography. You say that you would like reconsideration based on the records submitted.The Plandenied your request. The Plan says this service is inclusive in the services of an approved study.The Plan follows Medicare rules. Medicare rules say that the results of the sleep tests identified can be used by a beneficiary's treating physician to diagnose OSA, that the use of such sleep testing technologies demonstrates improved health outcomes in Medicare beneficiaries who have OSA and receive the appropriate treatment, and that these tests are thus reasonable and 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 polysomnography. Our reviewer says that coverage criteria for 95810, diagnostic attended PSG, arenot met. Our physician reviewer found this service is part of, and therefore duplicates 95811, which has been approved.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 polysomnography have not been met.Therefore, we decided that the Plan does not have to pre-approvepolysomnography (95810).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided on September 11, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe physician services. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe physician services provided on September 11, 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 cost sharing forthe specialist and injection services rendered to you on September 19, 2019.You asked the Plan to waive the cost sharing forthese services. You say that you disagree with the charges.The Plan denied your request. The Plan says the cost sharing was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract withthe Plan clearly says that you must pay a $50 copayment for in-network specialist services and a 20% coinsurance for in-network Medicare Part B covered drugs.Review of the file shows that you received specialist services on September 19, 2019. You have been asked to pay a $50 copayment for these services. These services fall within the in-network specialist services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The file shows that you received a drug injection on September 19, 2019. You have been asked to pay a 20% coinsurance for these services, for a total of $2.40. These services fall within the in-network Medicare Part B covered drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The total amount you have been asked to pay for these services is $52.40. 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 forthe specialist and injection services rendered to you on September 19, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen concentrator (E1390) from July 30, 2019 through August 30, 2019.You asked the Plan to waive the coinsurance for the DME. You say that you were told by the hospital that during your discharge that you needed oxygen.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 show that you received an oxygen concentrator (E1390) from July 30, 2019 through August 30, 2019. You are asked to pay 20% coinsurance for the DME. 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 coinsurance for oxygen concentrator (E1390) from July 30, 2019 through August 30, 2019
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 LTACH admission is medically necessary. The Plan denied your request. The Plan says the member does not have clinical conditions that cannot be appropriately treated in the current hospital.
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 current acute care services appear to be appropriately addressed, and transfer to LTACH would not provide any improvement in services or outcome. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe provided on February 20, 2019.You asked the Plan to reimburse you forthe Face Down Recovery System. You say that the Face Down Recovery System was medically necessary.The Plan denied your request. The Plan says the Face Down Recovery Systemis not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to reimburse you forthe Face Down Recovery System provided on February 20, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on October 14, 2019.
You asked the Plan to pay for the 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 Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on October 14, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a referral for a PET scan at a tertiary care center.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee can redirected to a community level provider to perform the PET scan.
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 referral. Our reviewer says that the requested referral is considered medically reasonable and necessary in this case. Our physician reviewer found clearly PET/CT is indicated for staging in this patient with biopsy proven anal carcinoma and left inguinal nodal metastasis. The enrollee is being treated with targeted radiation therapy at the facility and the notes indicate a need for simulated scanning for such therapy meaning it is necessary to do the test at the facility as simulation from an outside facility scan would not be possible. 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 referral have been met. Therefore, we decided that the Plan has to pre-approve a referral for a PET scan at a tertiary care center.
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 an office visit provided on September 10, 2019.
You asked the Plan to waive the copayment for specialist visit. You say that this was a follow-up visit and you were told you would not have a copayment. 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 $40 copayment for specialist visit. You have been asked to pay $40 copayment for specialist visit. specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 office visit provided on September 10, 2019.
Your complaint regarding receiving inaccurate information about the cost-share for this service 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 waive the copayment forlaboratory services provided on September 12, 2019.You asked the Plan to waive the copayment forlaboratory services. You say that this was ordered as partof your annual wellness physical. You say that you have never paid a copayment for this before.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 $35 per day, per provider, for in-network Medicare-covered lab services. You have been asked to pay $29.62, which is less than the standard $35 copayment for laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 forlaboratory services provided on September 12, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided on July 20, 2018.You asked the Plan to pay forthe physician services. You say that you would like the plan to reconsider their denial of payment.The Plandenied your request. The Plan says the claim was not filed timely per Medicare guidelines.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year afterthe date of service.The record shows that a claim for the physician services was not filed until August 16, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe physician services provided on July 20, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the sleep study (95811) provided on July 22, 2019.You asked the Plan to waive the copayment for the sleep study (95811). You say that you feel you should not be responsible for this cost share amount.The Plan denied your request. The Plan says you received an outpatient diagnostic test 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 $200 copayment for Outpatient diagnostic tests. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a sleep study on July 22, 2019. You have been asked to pay a $200 copayment for the sleep study (95811). The sleep study (95811) provided in an outpatient hospital setting, 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 copayment for the sleep study (95811) provided on July 22, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on January 30, 2019.
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration as the services rendered were medically necessary. The Plan denied your request. The Plan says train of four is considered integral to the primary procedure, neurophysiology monitoring and therefore is part of a bundled payment.
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 95999 is not supported in the record. Specifically, payment for train of four monitoring is included in the payment for the approved neuromonitoring services. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on January 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe aspirin, clopidogrel, rosuvastatin, duloxetine, amlodipine, gabapentin and metoprolol tartrate provided on July 26, 2019.You asked the Plan to pay forthese drugs. The Plan denied your request. The Plan says that these drugs are self-administered and not covered.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 forthe aspirin, clopidogrel, rosuvastatin, duloxetine, amlodipine, gabapentin and metoprolol tartrate provided on July 26, 2019.Benefits for these drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further informationconcerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitoring system.You asked the Plan to pre-approvea continuous glucose monitor. You say that you need a continuous glucose monitor.The Plan denied your request. The Plan says you are not on insulin and only check your glucose levels once per day.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea FreeStyle Libre continuous glucose monitoring system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEliquis Tab 5mg.You asked the Plan to pre-approveEliquis Tab 5mg. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.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-approveEliquis Tab 5mg.Benefits for Eliquis Tab5mgmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.