Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the physical therapy services (97110, G0283, 97010) provided on August 2, 2021.  You asked the Plan to waive the copayment for physical therapy. You say that you feel this claim should be reprocessed and covered in full. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment has been assessed in accordance with your contract. 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 $15 copayment for physical therapy.   You have been asked to pay a $15 copayment for physical therapy. 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 physical therapy services (97110, G0283, 97010) provided on August 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (76705) provided September 3, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed has a bundled relationship with another code 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, we have confirmed that code 76705 has a bundled relationship with code 76981. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (76705) provided September 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for air ambulance services provided on July 18, 2021.  You asked the Plan to pay for air ambulance services. You say that the air ambulance services were medically necessary. The Plan denied your request. The Plan says air ambulance services were not medically necessary.  The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.   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 air ambulance services. Our reviewer says that air ambulance services were not medically necessary. Our physician reviewer found that the emergency medical services responders recorded no obvious injuries and moving all extremities. The enrollee was hemodynamically stable. The enrollee was transported by air ambulance from hospital in Alice, TX to a hospital San Antonio, TX which was 49-minutes by air transport. The closest hospital with the necessary services would have been in Corpus Christi, TX, which was 52-minutes by ground ambulance. The enrollee was stable with a blood pressure of 132/78, cardiac rate and sinus rhythm, and oxygen saturation of 98% on ventilator assist. The Glasgow coma scale was not accurate as the enrollee was sedated. The enrollee's eyes opening and had appropriate responses to stimulation. The review has determined that the documentation did support that the enrollee suffered from an illness or injury that contraindicates transportation by any means other than ambulance. The documentation did not support that the enrollee's condition was such that the time needed to transport by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance services provided on July 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency anesthesia rendered on October 29, 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 the services are not separately payable.  The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.   We looked at the file and Medicare rules. Billed procedure code 99140 (emergency anesthesia) has a status indicator of B and no separate payment. Therefore, we decided that the Plan does not have to pay for the emergency anesthesia rendered on October 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital stay from May 26, 2021, to June 3, 2021.  You asked the Plan to waive the copayment for inpatient hospital stay. You say that the copayment should be waived because the medication was not received on time. The Plan denied your request. The Plan says the copayment amount the enrollee was charged was correct.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay $295 copayment per day, days 1 to 6 for each inpatient hospital stay. This inpatient stay was a total of 8 days, resulting in a copayment amount of $1,770.   The enrollee has been asked to pay $295 copayment per day, days 1 to 6 for inpatient hospital stay. Inpatient hospital stay falls within the Inpatient Hospital Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital stay from May 26, 2021, to June 3, 2021.   Your complaint regarding the enrollee's experience during this hospital stay is considered to be a grievance. Maximus Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the esophagogastroduodenscopy, flexible, transoral; with an endoscopic ultrasound examination (43259) provided on August 9, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 $275 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.    You have been asked to pay a $275 copayment for the Medicare-covered surgery provided at an outpatient hospital. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy, flexible, transoral; with an endoscopic ultrasound examination (43259) provided on August 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on June 14, 2021.  You asked the Plan to pay for physician's services. 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 physician's services provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on July 7, 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 office visit (99214) rendered by the out-of-network (OON) provider on July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the influenza vaccine (90653) and the administration of the vaccine (G0008) rendered by the out-of-network (OON) provider on September 23, 2021.  You asked the Plan to pay for this item/service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this item/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 item/service 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 this item/service. Therefore, we decided that the Plan does not have to pay for the influenza vaccine (90653) and the administration of the vaccine (G0008) rendered by the out-of-network (OON) provider on September 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital care provided December 22, 2020 to December 26, 2020.  You asked the Plan to pay for inpatient hospital care. You say that the services were medically necessary and properly billed. The Plan denied your request. The Plan says DRG 292 more accurately reflects the services provided.  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.    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 inpatient hospital care. Our reviewer says that the records support DRG 292. Our physician reviewer found the documentation received was incomplete to reflect evidence of significant ongoing respiratory distress beyond that on initial presentation which resolved with acute treatment of acute diastolic heart failure exacerbation.   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 inpatient hospital care provided December 22, 2020 to December 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for an oxygen concentrator (E1390) provided on July 20, 2021.  You asked the Plan to pay for an oxygen concentrator. You say that the item at issue was a necessity for you as your previous supplier was not satisfactory. The Plan denied your request. The Plan says rules for payment have not been met because the supplier of the item at issue is not enrolled in the Medicare program.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for an oxygen concentrator (E1390) provided on July 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Daliresp.  You asked the Plan to pre-approve Daliresp. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Daliresp.    Benefits for Daliresp may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance ride provided on September 26, 2021.  You asked the Plan to waive the copayment for the ambulance ride. You say that the enrollee had reached their maximum out-of-pocket amount and should not be responsible for the copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.   The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $240 copayment for each separate in- and out-of-network Medicare-covered ambulance services.   The enrollee has been asked to pay a $240 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. The record shows the provider was out-of-network and the copayment was applied to the combined maximum out-of-pocket amount that had not been met at the time of service.  This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance ride provided on September 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (69990) provided July 22, 2021.  You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code shares a bundled relationship with another code billed and is 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 69990 has a bundled relationship with code 63042. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (69990) provided July 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (76700) provided August 2, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed has a bundled relationship with another code billed and is 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.  We find that CPT code 76700 is not supported in the medical record. Specifically, this code shares a bundled relationship with CPT code 93976 which was also billed. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (76700) provided August 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (82274, 82656, 82705, 83520, 83631, 87177, 87209, 87338, 87798, 89055) provided November 17, 2020.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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.  We find that CPT codes 82274, 82656, 82705, 83520, 83631, 87177, 87209, 87338, 87798, & 89055 are not supported in the medical record. Specifically, the place of service listed on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (82274, 82656, 82705, 83520, 83631, 87177, 87209, 87338, 87798, 89055) provided November 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for laryngoscopy procedures (31579) provided on April 27 and June 8, 2021.  You asked the Plan to waive the copayments for laryngoscopies. You say that the services provided should not be classified as outpatient surgery. The Plan denied your request. The Plan says the correct copayments were applied.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for Medicare-covered surgery or other services.   You have been asked to pay a $350 copayment per date of service for laryngoscopies.   Laryngoscopies fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 copayments for laryngoscopy procedures (31579) provided on April 27 and June 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia.  You asked the Plan to pre-approve Prolia. You say that the drug is medically necessary. The Plan denied your request. The Plan says Prolia to be administered at home is not Medicare covered under the Part A or B benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on February 5, 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 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 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 laboratory services rendered on February 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (76775) provided September 20, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code shares a bundled relationship with another code 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, we have confirmed that code 76775 has a bundled relationship with code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (76775) provided September 20, 2021.