Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on February 10, 2020.
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that you were not advised that you would be responsible for a $25 copayment. The Plan denied your request. The Plan says this claim was processed at the in-network allowable amount with an enrollee responsibility of $25.
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, you are responsible for a $25 copayment for covered preventive and diagnostic dental services. Therefore, we decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on November 25, 2019.You asked the Plan to pay for the drug testing. You say that this is supported by the documentation.The Plan denied your request. The Plan says there is no validsigned order from the provider.The Plan must follow Medicare rules. Medicare rules say that laboratory testing may be covered when ordered by the treating provider. In this case, the file includes several copies of an order form. None are signed by the ordering physician, and there is one form in which none of the options are checked. Other submitted forms do include a X in the box for Custom Profile; however, there is no indication elsewhere in the file defining what is included in this custom profile. There is a reference to this testing in the progress note provided but it simply references a drug screen but does not give further detail. Taken together, the documentation does not clearly demonstrate the intent to perform the specific testing provided.Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on November 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on February 5, 2020.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 the Guardant360 panel must be billed with procedure code 81479.The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the Guardant360 panel rendered on February 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a screening mammography and a DXA, bone density study provided on March 6, 2020.You asked the Plan to pay for the screening mammography and a DXA, bone density study. The Plan denied your request. The Plan says he 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, has been 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 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 a screening mammography and a DXA, bone density study provided on March 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthoses with suspension sleeves (L1833, L2397) provided to the enrollee on March 19, 2020.
You asked the Plan to pay for the orthoses. 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 knee orthoses with suspension sleeves (L1833, L2397) provided to the enrollee on March 19, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychological services provided on February 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychological services. You say that the provider rendered these services in good faith and should be reimbursed for the medically necessary care. The Plan denied your request. The Plan says these services were provided out of network without prior authorization being sought. There are network provider available to provide this 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 for the psychological services provided on February 25, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 30, 2019 and January 6, 2020.You asked the Plan to pay for the laboratory 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 Plandid not pre-approve the laboratory services. 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 December 30, 2019 and January 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for sterile gauze, non-impregnated (A6219) Alginate dressing (A6196) provided December 23, 2019.
You asked the Plan to pay for surgical dressing. You say that there is a contract with the nursing home to send wound care supplies to all the patients with Medicare Part B benefits. They could not have gotten the supplies from any other vendor. The Plan denied your request. The Plan says the services are a part A benefit for skilled nursing facility admissions and are included in the facility PPS payment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that surgical dressing was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for sterile gauze, non-impregnated (A6219) Alginate dressing (A6196) provided December 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating hospital on March 12, 2020 to March 17, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you only had to stay due to the hospital's mistake. 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 per day for days 1-6 for inpatient hospital care. You have been asked to pay a $275 copayment per day for days 1-4 for an inpatient hospital stay. The total amount you are being asked to pay is $1,100 ($275 x 4 days = $1,100). An inpatient hospital stay falls within the inpatient hospital 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 for an inpatient hospital stay provided by a participating hospital on March 12, 2020 to March 17, 2020.
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair.
You asked the Plan to pay for a shower chair. You say that the shower chair was required by the home health and hospice agency that was providing care for the enrollee. You asked the Plan to reconsider providing coverage. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extractions provided on March 2, 2020.You asked the Plan to pay forthe extractions. You say that the dentist was listed as an in-network oral surgeon. You say that youpaid in full and you should receive payment.The Plan denied your request. The Plan says the services are not covered benefits.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 among those covered under this benefit.Therefore, we decided that the Plandoes not have to pay forthe extractions provided on March 2, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating hospital on March 9, 2020 to March 11, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you had to stay in the hospital due to the hospital's mistake. 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 per day for days 1 to 6. There is a $0 copayment for additional days for inpatient hospital care. You have been asked to pay a $275 copayment per day for days 1 to 2. The total amount you are being asked to pay is $550 ($275 x 2 days = $550). An inpatient hospital stay falls within the inpatient hospital 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 for an inpatient hospital stay provided by a participating hospital on March 9, 2020 to March 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 11, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. 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, has been 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 and the referring provider are not network providers with the Plan. The Plan did not pre-approve the laboratory services. 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 December 11, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99285) provided on March 15, 2020. You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT 99285 is used by any physician seeing a patient registered in the emergency department and emergency department coding is not appropriate if the site of service is an outpatient setting.
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 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. We find that CPT code 99285 is not supported in the record. Specifically, CPT code 99285 is for an emergency department visit. This claim was submitted with place of service code 22 for, "On Campus-Outpatient Hospital." It is inappropriate to bill emergency department coding when the site of service is not an emergency department. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency department visit (99285) provided on March 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora wig, any type (A9282) provided November 14, 2019.You asked the Plan to pay fora wig. You say that the medical records provided support the necessity of the services.The Plan denied your request. The Plan says this services are not covered under Medicare or the Plan.Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules.In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig.Therefore, we decided that the Plan does not have to pay fora wig, any type (A9282) provided November 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on October 14, 2019.You asked the Plan to pay for the drug panel. You say that this was medically necessary and should be covered.The Plan denied your request. The Plan says there is no valid order indicating that this specific testing was requested.The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a treating provider.In this case, the order form indicates a certain panel with a specific code was ordered. The file included a form identifying the provider's custom panel; however, the order form does not clearly indicate that this panel code is for the custom panel.Therefore, we decided that the Plan does not have to pay forthe definitive drug testing provided on October 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe resin-based composite provided on October 8, 2019.You asked the Plan to pay forthe resin-based composite. You say that your front tooth cracked, and you do not think you could go with a front tooth cracked.The Plan denied your request. The Plan says this service is not a covered benefit under your dental planMedicare 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 among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe resin-based composite provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the debridement service provided on March 10, 2020.
You asked the Plan to waive the copayment for the debridement service. You say that you should not have a copayment because this provider is your surgery doctor and you are supposed to see her. 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 $15 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office visit. You have been asked to pay a $15 copayment for the debridement service. The debridement service falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the debridement is considered a surgical service that was done in the specialist's office.
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 debridement service provided on March 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forfoot orthotics.You asked the Plan to pay forfoot orthotics. You say that your doctor's prescription for the orthotics should be evidence for the Plan to reconsider their denial. You asked the Plan to provide coverage and reimburse you for the cost of the orthotics.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pay forfoot orthotics.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on February 12, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says 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, has been 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 psychotherapy services. 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 psychotherapy services provided on February 12, 2020.