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

We decided that the Plan does not have to waive the copayment for a semi-electric hospital bed (E0260) and nebulizer (E0570) provided from April 12, 2019 to September 16, 2019 by the provider.
You asked the Plan to waive the copayment for the semi-electric hospital bed and nebulizer. You say that you should not be responsible for the rental fee since you were not advised of the charges when the equipment was delivered. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 20% coinsurance for durable medical equipment. You have been asked to pay $96.55 for the semi-electric hospital bed and nebulizer. $18.81 ($94.05x20%) per month for 5 months = $94.05 + $2.50 ($12.51x20%) = $96.55. A semi-electric hospital bed and nebulizer fall within the durable medical equipment 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 a semi-electric hospital bed (E0260) and nebulizer (E0570) provided from April 12, 2019 to September 16, 2019 by the provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from January 16, 2019 to February 27, 2019 billed with code S9328.
You asked the Plan to pay for the HIT services. You say that payment should be made for this medically necessary service. The Plan denied your request. The Plan says the code being billed is not payable by Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code S9328 has a status indicator of "I" on the Physician Fee Schedule. This means that it is invalid for Medicare payment purposes. Based on this information, we decided that Medicare rules for coverage of the HIT services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from January 16, 2019 to February 27, 2019 billed with code S9328.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99212) provided by the physician on August 20, 2019.
You asked the Plan to waive the copayment for an office visit. You say that when the doctor came in to see you that he did nothing for you but say everything is fine. You say one of the nurses could have called to ask how you were doing and it would have been the same. The Plan denied your request. The Plan says physician services with a specialist has a $35 copayment per visit.
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 $35 copayment for physician services per visit. You have been asked to pay a $35 copayment for an office visit. This service falls within the physician 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 office visit with a specialist (99212) provided by the physician on August 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage of an abscess provided on April 12, 2019 by the out of network provider.
You asked the Plan to pay for the incision and drainage of an abscess. You say that the provider was not aware he was out-of-network. The Plan denied your request. The Plan says these services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 incision and drainage of an abscess provided on April 12, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a vitrectomy recovery chair provided by the provider from May 12, 2019 to May 19, 2019.
You asked the Plan to pay for vitrectomy recovery chair. You say that you are requesting payment. The Plan denied your request. The Plan says the denial of payment for this item is correct, because this item is not covered by Medicare.
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. Medicare has determined that face down positioning devices are statutorily non-covered by Medicare. Therefore, we decided that the Plan does not have to pay for a vitrectomy recovery chair provided by the provider from May 12, 2019 to May 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by the practice on August 1, 2019.
You asked the Plan to waive the copayment for the ambulance services. The Plan denied your request. The Plan says the ambulance 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). The enrollee's contract with the Plan clearly says that enrollees must pay $300 copayment for ambulance services. The enrollee has been asked to pay a $300 copayment for the ambulance services. The file shows that the allowable amount for these services is $224, which is less than the $300 copayment. The ambulance services falls within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation that the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran eye exam (92014) provided by the provider on September 24, 2019.You asked the Plan to waive the copayment foran eye exam. You say that you were told that you were covered in full for a routine eye exam.The Plan denied your request. The Plan says a medical exam and evaluation, with continuation of a diagnostic and treatment program has a $50 copayment.The rules say a plan must disclose to its enrollees in clear, accurateterms 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 a medical eye exam. You have been asked to pay a $50 copayment for an eye exam. This service falls within the Vision care 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 foran eye exam (92014) provided by on September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora medical eye exam provided by the provider on September 23, 2019.You asked the Plan to waive the copaymentfora medical eye exam. You say that you thought that you were receiving a routine eye exam and should not owe a copayment.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $50 copayment medical eye exams for vision care. The medical records show that you received a medical eye exam on September 23, 2019. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for a medical eye exam. A medical eye exam falls within the vision care 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 decidedthat the Plan does not have to waive the copayment fora medical eye exam provided on September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing provided on August 24, 2018.You asked the Plan to pay for the train of four testing. The Plan denied your request. The Plan says train of four testing is considered a bundled procedure.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 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 train of four testing. Our physician reviewer found that train of four monitoring is bundled with the intraoperative neuromonitoring of electromyography (EMG), or motor evoked potentials (MEP). Therefore, the service is not separately reportable. There is no CPT code used to separately bill for train of four services.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 train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing provided on August 24, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

How we made our decision  1. We read all the papers in the file.2. We checked Medicare rules.3. We checked the contract with the Plan. 4. If required, we sent the file to a MAXIMUS Federal Services physician reviewer.To make our decision we read all the papers in the file very carefully. We used the Medicare rules. We looked to see if the Plan correctly followed Medicare rules and regulations.Medicare rules say that the Plan must give the member a subscriber agreement. It is a contract between the Plan and the member. It is usually called the "Evidence of Coverage" (EOC) or "Member Agreement."We read this contract carefully to see what the Plan is supposed to cover.The Plan sent additional information to us. This information was not received in the original case file from the Plan. Our decision was made using all of the information we received.Medicare rulesThe rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract also includes a list of covered supplemental dental benefits. The post and core, the pontics and retainer crown are not on this list and are not covered supplemental benefits. You can find this information on pages 63 to 68 of the Plan's 2019 Evidence of Coverage.Explanation of decision We decided that the Plan does not have to pay forthe post and core, the pontics and retainer crown provided on August 22, 2019.You asked the Plan to pay forthe post and core, the pontics and retainer crown. You say that the treatment the doctor provided was necessary to improve your dental health condition. You say that you do not agree with the crowns not being covered.The Plan denied your request. The Plan says these are not covered benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefitthat 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 forthe post and core, the pontics and retainer crown provided on August 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fo rthe laboratory testing provided to the enrollee on June 3, 2019.You asked the Plan to pay for the laboratory 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 a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The documentation does not support that the laboratory testing at issue in this appeal was not requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on June 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery and outpatient rehab services provided on December 14, 2019 to March 15, 2019.You asked the Plan to waive the copayment for an outpatient surgery and outpatient rehab services. You say that you were told that your surgery was 100% covered. You say that you are that you are now receiving a bill which you feel is unfair.The Plan denied your request. The Plan says the correct copayment has been applied.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 $275 copayment and a $35 copayment foroutpatient surgery/in-network/in-network and outpatient rehabilitation services/in-network/occupational therapy. You have been asked to pay a $275 copayment for an outpatient surgery and a $35 copayment for outpatient rehab services. The total amount you are being asked to pay is $590 ($275 + $315 ($35 x 9 = $315) = $590). An outpatient surgery falls within the outpatient surgery/in-network/in-network and outpatient rehab services falls within the outpatient rehabilitation services/in-network/occupational therapy 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 outpatient surgery and outpatient rehab services provided on December 14, 2019 to March 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor coded K0553 provided on July 28, 2019.You asked the Plan to pay for the supply allowance for therapeutic continuous glucose monitor. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed were billed incorrectly.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 K0553 is Supply allowance for therapeutic continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service. We find that CPT code K0553 is not supported in the medical record. Specifically, this code was billed with a modifier that is inappropriate for this code. The KF modifier is not appropriate for this code. Based on this information, we decided that Medicare rules for coverage of the supply allowance for therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay forthe supply allowance for therapeutic continuous glucose monitor coded K0553 provided on July 28, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for pulmonary stress testing provided on August 5, 2019. You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. 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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services for pulmonary stress testing provided on August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 31, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy treatment (97039) and the office visit (99202) provided from May 17, 2019 to May 23, 2019.You asked the Plan to pay for these services. You say that you are requesting reconsideration of the Plan's denial.The Plan denied your request. The Plan says the services provided are not a covered benefit under the member's policy.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the physical therapy treatment (97039) and the office visit (99202) provided from May 17, 2019 to May 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhome enteral nutrition therapy (S9342) provided from July 15, 2019 to July 18, 2019.You asked the Plan to pay forhome enteral nutrition therapy. You say that this code is a contracted code.The Plan denied your request. The Plan says this code is not valid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code S9342 is home therapy; enteral nutrition via pump; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem. It has a status code of "I."We find that CPT code S9342 is not supported in the medical record. Specifically, this code has a status code of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home enteral nutrition therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome enteral nutrition therapy (S9342) provided from July 15, 2019 to July 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (an MRI) (72148) on June 27, 2019.
You asked the Plan to waive the copayment for an MRI. You say that you are being railroaded. You say you do not know how you have a copay for services rendered. The Plan denied your request. The Plan says outpatient diagnostic tests and services have a $225 copayment. The Plan also says this service includes advanced imaging (services such as an MRI).
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 diagnostic tests and services. You have been asked to pay a $200.72 copayment for an MRI. This service falls within the outpatient diagnostic tests and services benefit category. The allowable Medicare amount for this procedure is $200.72 which is less than your normal stated copayment of $225. 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 magnetic resonance imaging (an MRI) (72148) on June 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not havetopay fordrug testing services provided to "the beneficiary" on May 20, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysHealthcare Common Procedure Coding System (HCPCS) G0482 (1 Unit) remains not supportedThe Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided to "the beneficiary" on May 20, 2019.