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

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on June 7, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 services at issue in this appeal. 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 the services provided by an out-of-network provider on June 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services billed with diagnosis related group 
(DRG) code 291 provided from May 19, 2020, to May 22, 2020. 
 
You asked the Plan to pay for the inpatient services billed with DRG 291. You say that it is unclear why the 
Plan adjusted the claim from DRG 291 to DRG 292. You also say that the provider was correct in billing 
J96.21 (acute and chronic respiratory failure with hypoxia). The Plan denied your request. The Plan says DRG 
291 is not supported as the diagnoses of acute and chronic respiratory failure with hypoxia (J96.21). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, J96.21, defined as acute 
and chronic respiratory failure with hypoxia. 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 pay for the 
inpatient services billed with DRG 291. Our reviewer says that DRG 291 is not supported. Our physician 
reviewer found the review indicates that the enrollee was a then 67-year-old with a history of morbid 
obesity, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), congestive heart 
failure (CHF), and deep vein thromboses (DVTs) who presented to the emergency department on May 19, 
2020 with increased shortness of breath. Our reviewer found that the enrollee was evaluated and admitted for 
right lower lobe atelectasis and an exacerbation of COPD. The enrollee was treated with supplemental oxygen, 
nebulizer treatments, antibiotics, intravenous diuretics, oral steroids, and continuous positive airway pressure 
therapy (CPAP). Our physician reviewer also found that the review has determined that the medical records do 
not support the billing of acute and chronic respiratory failure with hypoxia (J96.21).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient services billed with diagnosis related group (DRG) code 291 provided from May 19, 2020, to 
May 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like the LTACH care 
covered. The Plan denied your request. The Plan says you are receiving appropriate in-patient acute care and do 
not require transfer to LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided necessitating admission to an LTACH. You 
are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that 
are not available at the acute care hospital where you are currently receiving care. There are no services 
available at the LTACH that you require that are not available at the health care setting being offered by the 
health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your 
diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, first 30-74 minutes (99291) provided on March 19, 2021.
You asked the Plan to pay for the critical care. You say that this code was billed correctly. The Plan denied your request. The Plan says documentation does not support this code as billed.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the code provided is a time-based service and the time spent on this care is not indicated in the record. Based on this information, we decided that Medicare rules for coverage of the critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first 30-74 minutes (99291) provided on March 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory panel rendered on March 11, 2021.
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 services are not covered.
The Plan must follow Medicare rules. The rules say that multiplex PCR respiratory viral panels of 6 or more
pathogens are non-covered.
We looked at the file and Medicare rules. The file shows that six or more pathogens were tested. 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 respiratory panel rendered on March 11, 2021.
Local Coverage Determination (LCD) L37764 and L37713 used in the Plan's determination are for the
incorrect jurisdiction and were not used in the Maximus determination.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a second unit of radiological supervision for change of percutaneous tube/drainage catheter (75984) provided on May 12, 2021.
You asked the Plan to pay for radiology service. You say that you are appealing with records to support this level of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the records only support one unit of this code which was already approved and paid.
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 75984 is change of percutaneous tube or drainage catheter with contrast monitoring (eg genitourinary system, abscess), radiological supervision and interpretation.
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for radiology service. Our reviewer says that this code does not meet the criteria for payment. Our reviewer found the records do not include sufficient documentation to validate that a second unit of 75984-26-59 was performed on this date of service. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiology service have not been met. Therefore, we decided that the Plan does not have to pay for a second unit of radiological supervision for change of percutaneous tube/drainage catheter (75984) provided on May 12, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for genetic testing services you received from
an out-of-network pathologist on January 8, 2021.
You asked the Plan to reduce the coinsurance for the genetic testing services. You say that you were not aware
that the pathologist and the ordering doctor were out-of-network. The Plan denied your request. The Plan says
you were charged this coinsurance 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 40%
coinsurance for out-of-network genetic testing.
You have been asked to pay 40% coinsurance for the genetic testing services. Neither the pathologist nor the
ordering doctor is in-network with your plan. 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 reduce the coinsurance for genetic
testing services you received from an out-of-network pathologist on January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical eye exam (92004) and eye refraction (92015) provided on June 11, 2021.
You asked the Plan to pay for the eye exam and refraction. You say that you called the Plan to verify the provider's network status, and this service was necessary to evaluate your suspected cataracts. You were told these services would be covered and you could have the exams together. The Plan denied your request. The Plan says the medical exam is covered and requires a $35 copayment according to your contract. However, Medicare does not cover eye refractions. The Plan can cover eye refractions through your supplemental benefit, but these services must be provided as part of a routine eye exam and received from a provider in the Plan's specified routine vision network.
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 each visit to a specialist for Medicare-covered benefits. 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 they are provided as part of a routine eye exam received from a provider in the Plan's specified routine vision network. You have been asked to pay a $35 copayment for the eye exam. The eye exam was provided to evaluate the possibility of cataracts and is therefore is considered a medical eye exam provided by a specialist. 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.
We looked at the file and the Plan's rules. Documentation shows that you received a medical eye exam to evaluate your eyes for potential cataracts. Eye refractions are only covered when they are received from a provider in the Plan's specified routine vision network as part of a routine eye exam. Therefore, we decided that the Plan does not have to pay for the medical eye exam (92004) and eye refraction (92015) provided on June 11, 2021.
Your complaint about potential misinformation from the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services, basic life support,
non-emergency transport (A0428) and ground mileage (A0425) provided June 16, 2021.
You asked the Plan to waive the copayment for the two ambulance transports. You say that the cost is too high.
The Plan denied your request. The Plan says the copayments were 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 for Medicare-covered ambulance services. Cost sharing applies for each one-way trip
You have been asked to pay a total of $494.42 ($247.21 x 2 transports) for the two ambulance transports. These
services fall within the Ambulance services benefit category. This means that you have been asked to pay less
than or equal to 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 ambulance services, basic life support, non-emergency transport (A0428) and
ground mileage (A0425) provided June 16, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760).
You asked the Plan to pre-approve an ultrasonic osteogenesis stimulator. You say that this device is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that an ultrasonic osteogenesis stimulator is subject to the criteria listed in the Medicare rules section. We looked at the file and Medicare rules. In this case, there were no X-rays included in the enrollee's documentation that support the request for the equipment.
Based on this information, we decided that Medicare rules for coverage of an ultrasonic osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428-HR)
provided on January 4, 2021.
You asked the Plan to pay for the transportation service. You say that the ambulance transport was medically
necessary. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 pay for the transportation service. Our reviewer says
that the transportation service is not medically necessary. Our physician reviewer found the provided
documentation does not support that other means of transport (such as stretcher van) were contraindicated for
the enrollee on January 4, 2021. The reviewer found that the documentation does not support that the enrollee
needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped
ambulance can provide for safe transport on January 4, 2021. The reviewer also found that the documentation
does not support that the ambulance transport on January 4, 2021, was medically reasonable and necessary for
the enrollee.
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 transportation service have not been met. Specifically, the file does not
support that other means of transport (such as stretcher van) were contraindicated for the enrollee. Therefore,
we decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428-HR)
provided on January 4, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on May 21, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that this ER visit was needed because your indwelling catheter was inserted incorrectly. The Plan denied your request. The Plan says you were charged this copayment 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 $90 copayment for emergency room visits. You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason for the ER visit.
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 (ER) visit you had on May 21, 2021.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on
May 22, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that this ER visit was needed because
your indwelling catheter was inserted incorrectly. The Plan denied your request. The Plan says you were
charged this copayment 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 $90
copayment for emergency room visits.
You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason
for the ER visit. 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 (ER) visit
you had on May 22, 2021.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the
appropriate Quality Improvement Organization for further review
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground mileage (A0425) provided on June 19, 2021.
You asked the Plan to pay for the transportation services. You say that the transportation was medically necessary. The Plan denied your request. The Plan says the transportation services were not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 pay for the transportation services. Our reviewer says that the transportation services are not medically necessary. Our physician reviewer found the provided documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee on June 19, 2021. The reviewer found that the documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on June 19, 2021. The reviewer also found that the documentation does not support that the ambulance transport on June 19, 2021, was medically reasonable and necessary for the enrollee.
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 transportation services have not been met. Specifically, the file does not support that other means of transport were contraindicated for the enrollee. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground mileage (A0425) provided on June 19, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold the enrollee harmless for the anesthesia services identified with code
99100 received by the enrollee on February 21, 2021.
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says that the services are not payable as billed.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.
The enrollee received the anesthesia services by a contract provider. The file does not show that the plan
provided notice that the anesthesia services would not be covered. Under Medicare rules, this means the
anesthesia services is considered approved by the plan. Therefore, we decided that the Plan has to hold the
enrollee harmless for the anesthesia services identified with code 99100 received by the enrollee on February
21, 2021.
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.