Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment formedical services provided on September 30, 2019.You asked the Plan to waive the copayment formedical services. Yousay that you saw a nurse practitioner. You say that this was not an urgently needed service.The Plan denied your request. The Plan says that the copayment applied correctly.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 did not submit records to support that the medical services were provided at an urgent care facility andthe explanation of benefits does not show the billedservices at issue.Therefore, we decided that the Plan hasto waive the copayment formedical services provided on September 30. 2019. f 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 pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve outpatient hospital services (G0463 and 80305). You say that you would like reconsideration because the services provided were vital to the member's health. The Plan denied your request. The Plan says out of network care is only covered in the case of an emergency or to receive dialysis out of the area, or with a 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 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 networkprovider 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 medical services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on July 17, 2019.
You asked the Plan to pay for the periodontal maintenance. You say that your regular dentist advised that only a periodontist can get under your gums clean enough to prevent sepsis. You also say that this is a true life and death situation. The Plan denied your request. The Plan says services are only covered when performed by a Plan provider. The Plan also says that you did not call prior to having the service performed to check coverage or request a coverage determination.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance provided on July 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCT scan of chest and orbit/sinus.You asked the Plan to pre-approvethe scan. You say that this is medically necessary.The Plan denied your request. The Plan says the lung nodule size was not provided.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pre-approve the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found there is no detailed neuro exam in the chart. There is no history of events leading tothe right-handweakness. If the neuro exam revealed appropriate findings for brain imaging, MRI would be the procedure of choice. Also, the description of sinusitis is vague, and not helpful. There is no documentation if plain films have been done. The presence of the right hearing loss is not quantified by the hearing test.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 scan have not been met.Therefore, we decided that the Plan does not have to pre-approveCT scan of chest and orbit/sinus
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmic diagnostic imaging test provided on August 8, 2019.
You asked the Plan to waive the copayment for the ophthalmic diagnostic imaging test. You say that you are requesting the plan to review this claim and remove the charge. 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 $65 copayment for each covered diagnostic procedure or test at a network doctor's office. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $65 copayment for the ophthalmic diagnostic imaging test.
You have been asked to pay a $39.75 copayment for the ophthalmic diagnostic imaging test. The ophthalmic diagnostic imaging test 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 diagnostic imaging test provided on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assistant surgeon services rendered on August 10, 2019.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 are not covered.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 11043. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for these services have not been met.Therefore, we decided that the Plan does not have to pay forthe assistant surgeon services rendered on August 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a hearing exam provided on October 22, 2019.You asked the Plan to pay for the hearing exam. You say that you were told by your PCP that you needed a hearing test, so you made an appointment with this provider and assumed this test would be covered by your insurance.The Plan denied your request. The Plan says you must see a TruHearing provider to use the hearing exam benefit.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing exambenefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing exams through TruHearing.We looked at the file and the Plan's rules. The provider in this case is not a networkhearingprovider with the Plan.Based on this information, we decided that the Plan's rules for coverage of the hearing exam have not been met. Therefore, we decided that the Plan does not have to pay for a hearing examprovided on October 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forwound debridement provided from August 7, 2019 to August 21, 2019.You asked the Plan to waive the copayments forwound debridement. You say that you should only owe a $20 copayment per each visit.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 $400 copayment for outpatient hospital surgery services.You received wound debridement from August 7, 2010 to August 21, 2019. Wound debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay the total allowed amount of $526.58, which is lessthan the total copayment amount.  You have been asked to pay $526.58 for wound debridement. Wound debridement falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forwound debridement provided from August 7, 2019 to August 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe genetic testing rendered on September 5, 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 testing is not covered.The Plan must follow Medicare rules. The rules say that MolDxwill reimburse approved testsWe looked at the file and Medicare rules. The testing at issue was not approved through the MolDx program for the date of service at issue.Therefore, we decided that the Plan does not have to pay forthe genetic testingrendered on September 5, 2019. The Plan references Local Coverage Determination (LCD) L35052 and L36082 in their determination; however, these LCDs are for the incorrect jurisdiction are were not used in the MAXIMUS determination
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveCXBladder testing provided to the enrollee on February 29, 2020.You asked the Planto pre-approvethe testing. You say that this test is a non-invasive procedure based on a bladder cancer molecular signature comprising the quantitative measurement of 5 mRNA biomarkers associated withurothelial cancer.The Plandenied your request. The Plansaysthis test has been determined to not be clinically valid, and is a non-covered test.The Plan must follow Medicare rules. Medicare rules say that CXBladder testing is not a covered service. This test continues to be non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plandoes not haveto pre-approveCXBladder testing provided to the enrollee on February 29, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 26, 2018 to July 24, 2018.
You asked the Plan to pay for home health services. You say that you were not aware that the final claim needed to be resubmitted. The Plan denied your request. The Plan says the final claim was not submitted after the RAP.
The Plan must follow Medicare rules. The rules say that a RAP and a claim will be submitted for each episode or period of care. Each claim must represent the actual utilization over the episode period. If the claim is not received 60 days after the calculated end date of the episode (day 120) or period (day 90) or 60 days after the paid date of the RAP (whichever is greater), the RAP payment will be canceled automatically by Medicare claims processing systems. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, a RAP was not originally submitted for these services. Once a RAP was submitted, a final claim was not submitted within the appropriate time frame. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from May 26, 2018 to July 24, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PMD.
You asked the Plan to pre-approve the PMD. You say that you had past knee and left hip surgery, as well as for the veins in your legs. In addition, you state that both feet are very swollen, and you have severe arthritis and osteoporosis which makes it difficult for you to walk and move around without an electric wheelchair to buy your groceries. The Plan denied your request. The Plan says you do not meet criteria for coverage of the PMD.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a PMD.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home visit provided on May 29, 2019.You asked the Plan to pay forthe home visit. You say that the enrollee did not have hospice covered on the date of service. You say the hospice enrollment was termed on May 13, 2019. The Plan denied your request. The Plan says the Medicare hospice benefits covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The record shows the proof of hospice election was April 22, 2019 to May 13, 2019. However, Medicare is still responsible for payment until the startof the next month after revocation. Therefore, we decided that the Plan does not have to pay forthe home visit provided on May 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on August 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that the services were provided to the enrollee in good faith. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee was referred for the services by an out of network provider. The Plan also says the services were not urgent or emergent.
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 referring provider is not a network provider either. 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 subsequent nursing facility care provided on August 23, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services rendered to the enrollee from August 30, 2019 to October 24, 2019.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 claims were not billed correctly.The Plan must follow Medicare rules. The rules say that a treatment authorization code is requiredfor home health claims.We looked at the file and Medicare rules. The home health claims were not billed with the required treatment authorization code.Therefore, we decided that the Plan does not have to pay forthe home health services rendered to the enrollee from August 30, 2019 to October 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveSymbicort.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is a drug you inhale and self-administer.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 Plandoes not haveto pre-approveSymbicort.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora mammogram provided on October 24, 2019.You asked the Plan to waive the coinsurance fora mammogram. You say that you had a mammogram and there was a fuzzy area of the image. You say that the doctor's requested another mammogram. You say that you should not be charged for the second mammogram.The Plan denied your request. The Plan says since a mammogram was provided the correct coinsurance 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 10% coinsurance for outpatient diagnostic tests/other diagnostic tests/in-network. You have been asked to pay a 10% coinsurance of the allowed amount for a mammogram. The total allowed amount is $204.26. The total amount you are being asked to pay is $20.43 ($204.26 x 10% coinsurance = $20.43). A mammogram falls within the outpatient diagnostic tests/other diagnostic tests/in-network 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 coinsurance fora mammogram provided on October 24, 2019.We note your complaint about having to get a second mammogram because of a fuzzy image. Your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that transfer to an LTACH is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria for transfer are not met.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 physicianreviewer found the enrollee doesnot require the type of care provided in a long-termcare facility. Medicare coverage criteria for transfer are not met.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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approveimmunohistochemical (IHC) staining of a skin biopsyYou asked the Plan to pre-approvethe testing. You say that this is medically necessary.The Plan denied your request. The Plan says this is not covered for this condition.The Plan must follow Medicare rules. Medicare rules say that IHC cannot be performed for skin lesions/biopsies.This testing is not covered in this clinical circumstance. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plan does not have to pre-approveimmunohistochemical (IHC) staining of a skin biopsy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on January 14, 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 a bundled procedure and payment for it is included in payment for the already approved neuromonitoring.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 service. 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 14, 2019.