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

We decided that the Plan does not have to reimburse you for hearing aids provided on June 18, 2021.
You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says hearing aids ordered through providers other than the Plan hearing aid provider are not covered.
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 ordered through the Plan's hearing aid provider. We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered through the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on June 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vitamin D assay rendered on May 27, 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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a Vitamin D assay, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Vitamin D assay rendered on May 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. You say that The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete denture - maxillary (D5110) provided by an outof-
network provider on June 29, 2021.
You asked the Plan to pay for a complete denture - maxillary. You say that you did not know that the provider
was not in-network. The Plan denied your request. The Plan says this provider has opted-out of Medicare.
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 due to the rendering physician opting out of Medicare. Therefore, we
decided that the Plan does not have to pay for a complete denture - maxillary (D5110) provided by an out-ofnetwork
provider on June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips to other health care related locations, such as a pharmacy or specialist.
You asked the Plan to provide additional routine transportation. You say that this transportation is necessary. The Plan denied your request. The Plan says trips in excess of the 48 offered by the Plan for medical locations other than your primary care physician's office are not covered.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 trips per year for locations other than your primary care physician's
office, such as a pharmacy or specialist's office. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation to locations other than your primary care physician's office. Therefore, we decided that the Plan does not have to provide additional routine transportation trips to other health care related locations, such as a pharmacy or specialist.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the abdomen and pelvis you had at an outpatient hospital facility on June 14, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that this copayment is a financial hardship for you. 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 $325 copayment for diagnostic radiology services that are not ultrasounds. You have been asked to pay a $325 copayment for the CT scan. The CT scan falls within the diagnostic radiology services that are not ultrasounds 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 computed tomography (CT) scan of the abdomen and pelvis you had at an outpatient hospital facility on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound guidance services coded 76937 provided on 
April 14, 2021. 
 
You asked the Plan to pay for the ultrasound guidance services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately 
payable. 
 
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, we have confirmed that code the 
ultrasound guidance services is an add-on code and has not been billed with an appropriate primary procedure 
code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the 
Plan does not have to pay for the ultrasound guidance services coded 76937 provided on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network outpatient mental health physician
services.
You asked the Plan to pre-approve out of network services. You say that there are no in-network providers
accessible to you that are accepting new clients The Plan denied your request. The Plan says out of network
mental health services are not a covered benefit. Maximus overturned the Plans denial. The Plan requested a
reopen and provided additional information. The Plan says that the records show you participated in Telehealth
visits out of network on June 2, 2021 June 16, 2021 and July 14, 2021. The Plan states they could have assisted
in arranging a telehealth visit with a network provider for these services.
The Plan is correct in this case. Medicare rules say that plans can require enrollees to get care from network
providers. The contract with the Plan says that the Plan must 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. Outpatient mental health care is not covered out of network.
The provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the services at issue in this appeal and can assist you to make the required appointments.
Therefore, we decided that the Plan does not have to pre-approve out of network outpatient mental health
physician services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you have a lack of urine control. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin injections provided on February 24, 2020. 
 
You asked the Plan to pay for the vitamin injections. You say that the patient has suffered from chronic pain 
and has tried other treatments that failed or had side effects. You say that the denial should be overturned, and 
the claim reprocessed for payment. The Plan denied your request. The Plan says the services are denied. 
 
The Plan must follow Medicare rules. Medicare rules say that Part B pays for outpatient physical therapy 
services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; 
or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA 
may perform physical therapy services under State law. Medicare rules also say that claims for compounded 
drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the vitamin injections have not been met. Specifically, we find that the physical therapy services at 
issue in this case were rendered by an NP who is not licensed to provide physical therapy. Also, the multiple 
drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that 
any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was 
not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration 
code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to pay for the vitamin 
injections provided on February 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided April 16, 2021 to June 16, 2021
You asked the Plan to waive the copayment for the inpatient stay. You say that due to lack of proper treatment and unnecessary prolonged stay you would like this reprocessed. The Plan denied your request. The Plan says these claims were processed with the correct copayments applied per the Evidence of Coverage.
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 $175 per day, per admission for days 1-7 $0 per day for days 8-90 for Inpatient hospital care. You have been asked to pay $2,657.37 ($1,225.00 $175 x 7 inpatient days provided April 16, 2021 to April 23,
2021 and $875.00 for $175.00 x 5 inpatient days provided June 11, 2021 to July 16, 2021) for the inpatient stay. The inpatient stay falls within the Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided April 16, 2021 to June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (99202, 97140, 72100) provided June 21, 2021 to July 19, 2021.
You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary. The Plan denied your request. The Plan says these services are non-covered when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services (99202, 97140, 72100) provided June 21, 2021 to July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown (D2740) provided on April 13, 2021. 
 
You asked the Plan to pay for the dental service. You say that the enrollee had a broken tooth. You say that 
they were in pain. You also say that the only way to stop the pain was to fit a crown. The Plan denied your 
request. The Plan says porcelain crown is not listed as a covered service. The Plan also says that the enrollee is 
not enrolled in the optional supplemental dental rider. 
 
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 porcelain crown is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the porcelain crown 
(D2740) provided on April 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home therapy services coded S9343 provided on April 28, 2021 to May 2, 2021.
You asked the Plan to pay for the home therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 S9343 is home therapy; enteral nutrition via bolus; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem.
We find that CPT code S9343 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home therapy services coded S9343 provided on April 28, 2021 to May 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (86580) rendered by the out-of-network (OON) provider on June 28, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (86580) rendered by the out-of-network (OON) provider on June 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have instability and trouble walking. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia supplies (S1015, S8301) provided November 3, 2020.
You asked the Plan to pay for the anesthesia supplies. You say that the items were medically necessary. The Plan denied your request. The Plan says the billed codes are not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes S1015, & S8301 are not supported in the medical record. Specifically, per the National Physician Fee Schedule, these codes have a status of "I" and are invalid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the anesthesia supplies have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia supplies (S1015, S8301) provided November 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vascular surgery and related invasive procedures.
You asked the Plan to pre-approve vascular surgery and related invasive procedures. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says the coverage criteria for the requested procedures have not 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 vascular surgery and related invasive procedures. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the patient is an 88-year-old woman who has already undergone bilateral greater saphenous vein ablation, right small saphenous vein ablation, and treatment of perforator veins bilaterally. There is documentation of pedal edema bilaterally. It is documented that the patient has improved significantly in terms of symptom reduction. Conservative treatment was recommended. Despite the improvement in symptoms, in one portion of the medical record she is being considered for additional sclerotherapy. There is no documentation of whole leg swelling. No rationale is provided as to why May-Thurner syndrome needs to be ruled out. The requested procedures are not medically reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of vascular surgery and related invasive procedures have not been met. Therefore, we decided that the Plan does not have to pre-approve vascular surgery and related invasive procedures.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for DME provided on June 25, 2021. 
 
You asked the Plan to pay for DME. 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 member's terminal 
condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the 
effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare 
also covers attending physician services and all care unrelated to the terminal illness until the first day of the 
month following the month in which hospice was revoked or discharged. 
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 DME provided on June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214, 36415) provided on July 26, 2021.
You asked the Plan to pay for the office visit. You say that the services were medically necessary, and the provider was in-network. The Plan denied your request. The Plan says this provider is out-of-network and there were network providers available.
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 service 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 an office visit (99214, 36415) provided on July 26, 2021.