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

We decided that the Plan does not have to pay for the moderate sedation services rendered on May 11, 2020 to May 12, 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 procedure code 99153 is not separately payable.

The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. 

We looked at the file and Medicare rules. Procedure code 99153 has a PC/TC indicator of 3 and no separate PC payment. Payment is included in payment to the facility. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on May 11, 2020 to May 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility stay.
You asked the Plan to waive the copayment for the skilled nursing facility stay. You say that no one informed
you that your coverage was only for twenty days. The Plan denied your request. The Plan says the correct cost
share amount applied to the claim.
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 $0 for
days 1 - 20 and a $178 copayment per day for days 21 - 100 for skilled nursing facility care.
You have been asked to pay $3315.44 for the skilled nursing facility stay. This stay falls within the skilled
nursing facility 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 the skilled nursing
facility stay.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that there was no record of member being able to tolerate 3 hours of therapy 5 days per week.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the extracranial bilateral study (93880) provided on October 5, 2020.
You asked the Plan to pay for the extracranial bilateral study. You say that you would like reconsideration because this service was performed in the correct place of service. The Plan denied your request. The Plan says this claim has been submitted with an inappropriate place of service code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 93880 is not supported in the record. Specifically, the record indicates that the member was registered inpatient on the billed date of service. It is not appropriate to bill an outpatient place of service code when the member is registered inpatient. Based on this information, we decided that Medicare rules for coverage of the extracranial bilateral study have not been met. Therefore, we decided that the Plan does not have to pay for the extracranial bilateral study (93880) provided on October 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 5, 2020, through August 12, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because the member is still in intensive care and cannot afford to pay for these services. The Plan denied your request. The Plan says the provider has not billed this claim correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the provider has billed the items on the claim with modifier 26. The codes billed all have a professional/technical component indicator of 9. This means that the 26 modifier is not appropriate in this case. Therefore, we decided that the Plan does not have to pay for laboratory services provided on August 5, 2020, through August 12, 2020. Please note, the Plan has indicated that you are not liable for payment of these services. If the provider is billing you for these services, please contact the Plan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on November 9, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you were not aware that you would owe any additional charges besides the 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on November 9, 2020. The allowed amount is $159.62 and 20% of that is $31.92. You have been asked to pay the total coinsurance amount of $31.92 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug provided on November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the eyeglasses purchased on June 30, 2020.
You asked the Plan to reimburse you for the eyeglasses. You say that the vision plan representative told you that you could go to this out of network provider. The Plan denied your request. The Plan says your plan does not allow reimbursement for services from a provider who is not a preferred network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when you must use network providers. We looked at the file and the Plan's rules. The record shows you were advised at the point of sale that the provider was not a network provider for your vision plan. This provider is not a Plan preferred provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for the eyeglasses purchased on June 30, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on October 5, 2020.

You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment. 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 $90 copayment for emergency care. 

You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency 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 the emergency room visit provided on October 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's treatment plan goals could be safely achieved in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not require intensive physician or nursing supervision in an IRF. While the patient may benefit and participate in multiple therapies the patient's functional level does not require this on an intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for a screening colonoscopy provided on October 21, 2020.
You asked the Plan to waive the copayment for a screening colonoscopy. You say that this was a preventative colonoscopy and you disagree with the charges. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $0 copayment for colorectal cancer screenings. The medical records indicate that you received a colonoscopy screening on October 21, 2020. The medical records show that no polyps were removed. Furthermore, there is no indication that the benefit was exhausted at the time a screening colonoscopy took place. Therefore, you cannot be asked to pay a copayment for the screening colonoscopy. The Plan says you must pay a $200 copayment for a screening colonoscopy. Based on the Plan contract, however, you cannot be asked to pay for a screening colonoscopy. Therefore, we decided that the Plan has to waive the copayment for a screening colonoscopy provided on October 21, 2020.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on November 11, 2020.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you would like to appeal this service. The Plan denied your request. The Plan says you had exhausted your dental x-ray benefit.
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, dental x-rays are limited to 1 per year. The record shows that you received a panoramic x-ray on November 11, 2020, and your dental x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 27, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must
receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
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
physician's 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 physician's services provided on October 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on October 1, 2020.
You asked the Plan to pay for the unspecified preventative procedure (D1999), dental crown (D2740) or core
buildup (D2950). You say that you were not aware your dental insurance had changed. The Plan denied your
request. The Plan says according to your Evidence of Coverage and Annual Notice of Change, these services
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 dental
services provided on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation services received on
August 25, 2020.
You asked the Plan to pay for the comprehensive oral evaluation services. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the services received exceed your
benefit limit.
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. The Plan covers the
comprehensive oral evaluation services once every three years.
We looked at the file and Medicare rules. Review of the file shows that you last received a comprehensive oral
exam on June 18, 2019. Three years had not passed since you previously received a comprehensive oral exam.
Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral evaluation
services have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive
oral evaluation services received on August 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Faslodex (J9395) for the enrollee.

You asked the Plan to pre-approve Faslodex (J9395). You say that Faslodex (J9395)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. Our Medical Director says at issue is coverage for Faslodex (Fulvestrant). The Maximus Physician Reviewer determined that treatment of hormone-receptor (HR)-positive advanced breast cancer in postmenopausal women with disease progression following endocrine therapy is approved and appropriate. The Plan requested a reopen and argued that for the enrollee's condition, subsequent therapy with combination fulvestrant/anastrozole for hormone receptor (HR)-positive, HER2-negative recurrent breast cancer, do not have support in a Medicare-accepted compendia and Medicare-accepted medical journals. The Plan states that per NCCN Guidelines for Breast Cancer, single agent fulvestrant or fulvestrant in combination with a CDK4/6 inhibitor would be appropriate treatment options. Our Medical Director states that the medical records show the enrollee is a 67-year-old woman with a diagnosis of "ER+ clinical stage IIIA highly proliferative breast cancer", with micrometastases. The records show the cancer progressed while being treated with Letrozole, and then had good response to chemotherapy. Surgery was followed by treatment with Xeloda. Our Medical Director has concluded that the Plan is correct in this case. There is insufficient evidence to support the use of Faslodex (Fulvestrant) with Anastrozole. Medicare coverage criteria 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 Faslodex (J9395) have not been met. Therefore, we decided that the Plan does not have to pre-approve Faslodex (J9395) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on August 24, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says it is important for the enrollee to know which providers are part of our network because, with limited exceptions, the enrollee must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the Plan's network is not available, out-of-area dialysis services and cases in which the Plan authorizes use of out-of-network providers.
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
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services that you provided on August 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation and setup of a portable x-ray (Q0092, R0070) provided on October 22, 2020.
You asked the Plan to pay for the transportation and setup of a portable x-ray. You say that you would like reconsideration because the provider is a mobile unit providing their own equipment. The Plan denied your request. The Plan says these services are subject to consolidated billing and not separately billable.
The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A SNF stay, the transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation and setup of a portable x-ray have not been met. Specifically, this claim was billed with place of service code 31, indicating that the member was in a Part A SNF stay. This means that the services at issue are subject to consolidated billing. Therefore, we decided that the Plan does not have to pay for the transportation and setup of a portable x-ray (Q0092, R0070) provided on October 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan provided on October 7, 2019.
You asked the Plan to waive the copayment for the duplex scan. You say that you cannot pay this amount. 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 $35 copayment for diagnostic procedures and tests at an in-network specialist's office. You have been asked to pay a $35 copayment for the duplex scan. The duplex scan falls within the "Outpatient diagnostic test 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 duplex scan provided on October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this cannot be approved.
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 the monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available medical records do not support necessity of the device as defined by Medicare criteria as no in-person visit with the the treating practitioner to evaluate your diabetes control has been documented within six months prior to ordering the continuous glucose monitor, 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.