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

We decided that the Plan does not have to pay for the medical services provided on November 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the pain management services. You say that you would like reconsideration because you were unaware that this provider was not in the Plan's network. The Plan denied your request. The Plan says with limited exceptions, you must use network providers and this provider is not in your network.
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 medical services provided on November 14, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee's caregiver cannot provide adequate care to the enrollee in the semi-electric bed. The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant surgery services during the excision of a neck tumor provided on December 11, 2019.
You asked the Plan to pay for the assistant surgery services. You say that the services were chosen by the surgeon and the assistant had no choice. The Plan denied your request. The Plan says the services of an assistant surgeon, co-surgeon, or surgical team are not covered for this procedure.
The Plan must follow Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. We looked at the file and Medicare rules. The assistant surgery services in dispute were billed with CPT code 21556. This CPT code has an assistant surgery indicator of 1. Based on this information, we decided that Medicare rules for coverage of the requested surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for assistant surgery services during the excision of a neck tumor provided on December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visits to be provided by an oral surgeon.
You asked the Plan to pre-approve the outpatient office visits. You say that this treatment is medically necessary for you to be able to eat and live normally. The Plan denied your request. The Plan says dental services by an oral surgeon are not covered.
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 not received by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve the outpatient office visits to be provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient consultation rendered on July 28, 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 procedure code 88254 is not supported.The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.We looked at the file and Medicare rules. The provider submitted a claim for procedure code 99254. This code has a status indicator of I and is not valid for Medicare purposes.Therefore, we decided that the Plan does not have to pay for the inpatient consultation rendered on July 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided.
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 is not a network provider 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the periapical x-ray (D0220), the pulp vitality test (D0460), the cone beam CT capture and interpretation (D0364), and the retreatment of a previous root canal therapy (D3348) provided.
You asked the Plan to pay for the dental services. You say that you are aware that you do not have supplemental dental insurance. You say that you have had chronic sinus issues for years. You say that the dental issues you have are related to your sinus issues. You also say that because of this, they should be covered as a medical expense. The Plan denied your request. The Plan says the services that you received are dental in nature. The Plan also says the dental services were not preventive in nature and therefore are not covered.
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 limited oral evaluation (D0140), the periapical x-ray (D0220), the pulp vitality test (D0460), the cone beam CT capture and interpretation (D0364), and the retreatment of a previous root canal therapy (D3348) provided.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises provided on December 9, 2019.You asked the Plan to pay for the therapeutic exercises. You say that this claim is not related to the enrollee's time spent in hospice.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.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.Therefore, we decided that the Plan does not have to pay for the therapeutic exercises provided on December 9, 2019.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for home health services provided to the enrollee.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that in order to reprocess, a corrected claim is needed due to incorrect coding.
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 claim was denied due to incorrect coding. The plan has not provided any information to MAXIMUS that would show how the claim would need to be corrected to be resubmitted by the provider. The plan has not substantiated their denial. Therefore, we decided that the Plan has to pay for home health services provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on January 8, 2020.
You asked the Plan to pay for the assembly and operation of a pump. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of a pump have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two osseous surgeries and periodontal scaling and root planing provided by an OON provider.
You asked the Plan to pay for the two osseous surgeries and scaling and planing. You say that your primary dentist referred you to a periodontist because you needed emergency treatment. You also say that you are on a fixed income and borrowed money to pay for this treatment. The Plan denied your request. The Plan says these services are not covered because they were provided by an OON provider.
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 OON. Therefore, we decided that the Plan does not have to pay for the two osseous surgeries and periodontal scaling and root planing provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim maxillary partial denture (D5820), two bone replacement grafts for ridge preservation (D7953 x2), and two guided tissue regenerations (D4266 x2).
You asked the Plan to pay for the interim maxillary partial denture, bone replacement grafts, and guided tissue regenerations. You say that you needed to have the bone graft and dental transplant so you can eat normally. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.
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 interim maxillary partial denture (D5820), two bone replacement grafts for ridge preservation (D7953 x2), and two guided tissue regenerations (D4266 x2).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on May 13, 2019.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the records do not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The file shows that the enrollee received presumptive drug testing, and definitive drug testing of 8-14 drug classes. We find that the services at issue are not supported in the medical record. There were insufficient records that show the tests were needed to identify specific substances. The records provided do not document concerns based on clinical review and judgement. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on May 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe radiology services provided on December 19, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe radiology services provided out of network. You say that the records provided support the need forthe services in dispute.The Plan denied your request. The Plan says the provider who supplied the radiology services in dispute is a non-network provider who does not work with the enrollee's health plan. The Plan says that the enrollee self-directed for this care and that there is no documentation that the services were 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe radiology services provided on December 19, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids.
You asked the Plan to pay for the hearing aids. You say that your appeal is simply to obtain the $500
reimbursement. Initially you purchased Hi HealthInnovations hearing aids offered back in 2016 and they were
inadequate. The Plan denied your request. The Plan says enrollee's must receive their hearing services from a
network hearing service provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when purchased from a network hearing service provider.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for
hearing aids.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot inserts to be provided by an out of network (OON)
provider.
You asked the Plan to pre-approve the foot inserts provided out of network. You say that the diabetic shoes and
foot inserts from the in-network provider did not fit properly. You say that you returned them and got refitted 3
times, but that none of these fittings were acceptable. You say that you would prefer to get your diabetic shoes
and inserts from the out of network provider. The Plan denied your request. The Plan says the enrollee is
authorized to see an in-network qualified provider. The Plan says that unsubstantiated grievances the enrollee
may have with the in-network 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 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 network provider 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
foot inserts to be provided by an out of network (OON) provider.
Your complaint regarding the care you received from the in network provider is considered a grievance and
must be addressed by the Plan separately. Medicare does not permit us to make decisions about these types of
complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forlimited oral exam (D0140) and periapical x-ray (D0220) provided January 6, 2020.You asked the Plan to pay forthe dental service. You say that you have dental insurance and is entitled to the dental exam and x-rays. You were given this dental office name and number when you went online so you should not be charged out of network.The Plan denied your request. The Plan says these services are not covered under the plan 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. Services not listed under the Description of Benefitsis not covered by the plan.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 forlimited oral exam (D0140) and periapical x-ray (D0220) provided January 6, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional skilled nursing visits (G0299).
You asked the Plan to pre-approve additional skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, there is no indication you are home-confined. As such, the necessity for home health care services is not substantiated. Therefore, this request is not medically necessary.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy
You asked the Plan to pay for the occupational therapy. 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
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 occupational therapy
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care provided on January 8, 2020.
You asked the Plan to waive the copayment for vision care. You say that you feel that the services should be considered routine and have no 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 $20 copayment for eye exams to diagnose and treat diseases and conditions of the eyes. You received vision care on January 8, 2020. The claim was submitted with diagnostic codes showing that services beyond routine services took place. Therefore, you are responsible to pay the $20 copayment. You have been asked to pay a $20 copayment for vision care. Vision care 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 for vision care provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the anesthesia services.
You asked the Plan to waive the coinsurance for the anesthesia services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received anesthesia services in an outpatient hospital facility on the date of service at issue in this appeal. The Plan says the correct coinsurance has applied per your contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare-covered surgery or other services at an outpatient hospital or an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. We looked at the file, the Plan's contract and Medicare rules. The file shows you received anesthesia services in an outpatient hospital setting. You have been asked to pay a 20% coinsurance for the anesthesia services, totaling $51.62. The anesthesia services fall within the Outpatient surgery and Other Medical 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 coinsurance for the anesthesia services.