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

We decided that the Plan does not have to pay for the CxBladder test (0012M) provided on August 27, 2020.
You asked the Plan to pay for the CxBladder test. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are non-covered. We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we decided that Medicare rules for coverage of the CxBladder test have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder test (0012M) provided on August 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services.

You asked the Plan to waive the copayment for the services. You say that as the services were medically necessary, you shouldn't have to pay for this. The Plan denied your request. The Plan says the copayment 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 with the Plan clearly says that you must pay a $325 copayment for ambulance services.

You have been asked to pay a $325 copayment for the services. The services fall within the ambulance 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 ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Outpatient Substance abuse services provided from September 25, 2020, through October 8, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the Substance abuse services. You say that the services were medically necessary. The Plan denied your request. The Plan says since the services were provided by an OON provider who does not participate in Medicare and therefore are not covered.
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 had network providers available who could have provided 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 Outpatient Substance abuse services provided from September 25, 2020, through October 8, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the specialist office visit provided on
October 19, 2020.
You asked the Plan to waive the deductible for the specialist office visit. You say that this was a preventive
service that should not apply to the deductible and has a $0 copayment. The Plan denied your request. The Plan
says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $600 deductible that applies towards in-network specialist office
visits.
The specialist office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner
services, including doctor's office visits" benefit. The Plan has followed Medicare rules by clearly disclosing in
the contract that there is a $600 deductible that applies towards in-network specialist office visits. This cost
sharing is a contractual obligation that had not been met at the time the specialist office visit was received on
October 19, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the specialist
office visit on October 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator with a non-invasive interface.
You asked the Plan to pre-approve a home ventilator with a non-invasive interface. You say that the enrollee is in need of the requested equipment in order to breathe. The Plan denied your request. The Plan says the records provided do not support that the criteria for coverage have been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 a home ventilator with a non-invasive interface. Our reviewer says that the requested home ventilator is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has severe COPD and tracheobronchomalacia. A venous blood gas during an acute hospitalization suggests CO2 retention, but this is not confirmed with an arterial blood gas when clinically stable. There is no documented failure of BiPAP while at home in a stable state. Certain BiPAP devices are capable of providing the AVAPS-AE support mode that has been ordered for the ventilator, so the ventilator is being used as BiPAP, and this is not covered by Medicare.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator with a non-invasive interface have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator with a non-invasive interface.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic tests provided on June 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for diagnostic tests. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says there are in-network providers available for these services. The Plan says that prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 diagnostic tests provided on June 10, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiology services provided by a participating provider on November 9, 2020.
You asked the Plan to waive the copayment for radiology services. You say that you were never told that it would cost this much. 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 $175 copayment for outpatient diagnostic tests/advanced radiology service. You have been asked to pay a $175 copayment for radiology services. The correct copayment has been applied to the services that are provided. Radiology services fall within the outpatient diagnostic tests/advanced radiology service 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 radiology services provided by a participating provider on November 9, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the physician services with code 99217.

You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination within the allotted time frame.

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. In this case, the Plan denied payment for code 99217 due to incorrect place of service. On appeal, however, the Plan did not provide a determination within the allotted time frame. We find that the Plan has not substantiated their reasoning for denial of payment of code 99217 as the Plan provided no documentation or Medicare regulations showing that code 99217 is not payable in the place of service on the claim. Therefore, we decided that the Plan has to pay for the physician services with code 99217.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cataract surgery (65400) provided December 15, 2020.
You asked the Plan to waive the copayment for the cataract surgery. You say that the copayment is too expensive. The Plan denied your request. The Plan says the copayment 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 with the Plan clearly says that you must pay a $250 copayment per day for outpatient procedures and services, including, but not limited to, outpatient surgery performed in an outpatient hospital or ambulatory surgical center. You have been asked to pay a $250 copayment for the cataract surgery. This service falls within the Outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the cataract surgery (65400) provided December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening (D0190), oral hygiene instructions (D1330), preventive procedure (D1999), comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and prophylaxis (D1110) provided on December 14, 2020.
You asked the Plan to pay for the screening, oral hygiene instructions, preventive procedure, comprehensive oral evaluation, complete series of intraoral x-rays, and prophylaxis. You say that you would like these services to be covered. The Plan denied your request. The Plan says the $419.00 which was assessed as your OON liability is correct.
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 screening, oral hygiene instructions, and unspecified preventive procedure are not among those covered under this benefit. The contract clearly states that comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on July 25, 2018, and your comprehensive oral evaluation (D0150) benefit has been exhausted. The contract also clearly states that you are responsible for the difference between the billed amount and allowed amount for the complete series of intraoral x-rays and prophylaxis because they were rendered by an OON provider. The record also shows that the provider has waived the $20.00 fee for the preventive procedure (D1999). Therefore, we decided that the Plan does not have to pay for the screening (D0190), oral hygiene instructions (D1330), preventive procedure
(D1999), comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and prophylaxis (D1110) provided on December 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for
SNF care. The Plan denied your request. The Plan says there is no documentation to support that the enrollee
requires or will benefit from daily skilled therapy after he has already been receiving skilled therapy for the
past 5 months.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
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 SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled
services are not required to establish a maintenance program or to prevent deterioration of the enrollee's
condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a
lower level of care.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99349) provided by an out of network (OON) provider.

You asked the Plan to pay for the home visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were provided without prior authorization and do not meet OON criteria.

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 had network providers available who could have provided 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 home visit (99349) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
August 20, 2020.
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing facility care. 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 subsequent nursing facility care provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210) and the denture adjustment (D5650) provided on March 9, 2020.
You asked the Plan to pay for the dental services. You say that the extraction was medically necessary. You also says that you would like this claim to be covered as a one-time courtesy. The Plan denied your request. The Plan says extractions are not listed as a covered service. The Plan also says that denture adjustment is not listed as a covered service.
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 Plan does not have to pay for the extraction (D7210) and the denture adjustment (D5650) provided on March 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.

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 had network providers available who could have provided 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 lab work provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan for the enrollee for dementia.
You asked the Plan to pre-approve the requested scan. You say that this imaging is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a PET scan for dementia. The Maximus Physician Reviewer determined a PET scan was warranted. The Plan requested a reopen and stated that the coverage criteria established by NCD 220.6.13 were not met in this case, as there is no documentation that the enrollee met the diagnostic criteria for both Alzheimer's disease and frontotemporal dementia. The medical records show that the enrollee is a 78-year-old man who self-referred to neurology for memory decline. The enrollee scored 29/30 on MMSE. The enrollee was assessed to have mild cognitive impairment. Our Medical Director has concluded that the Plan is correct in this case. The documentation does not support that the enrollee meets diagnostic criteria for both Alzheimer's disease and frontotemporal dementia. The coverage criteria established by NCD 220.6.13 were not met in this case. 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 requested scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan for the enrollee for dementia.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cataract surgery (66984) provided November 9, 2020.
You asked the Plan to waive the copayment for the cataract surgery. You say that the facility should be classified as an ambulatory surgical center and therefore the copayment should be lower. The Plan denied your request. The Plan says the facility is considered an outpatient hospital building and the copayment 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 with the Plan clearly says that you must pay a $350 copayment for Outpatient hospital surgery. You have been asked to pay a $350 copayment for the cataract surgery. This service falls within the Outpatient hospital services benefit category. We checked the provider's National Provider Identifier (NPI) number and verified that this medical center is categorized as a General Acute Care Hospital. 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 cataract surgery (66984) provided November 9, 2020.