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

 We decided that the Plan does not have to waive the copayment for an ultrasound of the abdomen (76705) rendered on August 18, 2021.  You asked the Plan to waive the copayment for an ultrasound of the abdomen. You say that nowhere on your benefits does it show outpatient diagnostic for an ultrasound. You also say that this claim should be paid by your health insurance. The Plan denied your request. The Plan says you were 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 $75 copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service.   You have been asked to pay a $75 copayment for an ultrasound of the abdomen. an ultrasound of the abdomen falls within the diagnostic procedures and tests, including ultrasounds, at all locations of service 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 an ultrasound of the abdomen (76705) rendered on August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and cleaning (D1110) provided on November 3, 2021.  You asked the Plan to pay for the oral exam and cleaning. You say that you believed you were covered for two routine cleanings every year. The Plan denied your request. The Plan says your dental benefit covers up to a maximum of $1,000 for dental care each calendar year. You have met and exceeded this maximum benefit allowance and are responsible for any remaining costs.  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 up to a maximum of $1,000 for dental care per calendar year.   Though the Plan offers a dental benefit in excess of Medicare coverage, the items or services provided in excess of the Plan's calendar year maximum are not covered under this benefit. Documentation shows that you had met this maximum before the date in question. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and cleaning (D1110) provided on November 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (80177, 80157, 80159, 80173, 80162, and 80201) provided on February 25, 2020.  You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.    The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code 80177, 80157, 80159, 80173, 80162, and 80201 is not supported in the medical record. Specifically, the codes billed are for venipuncture procedures, however the lab requisitions show samples obtained via urine. 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 (80177, 80157, 80159, 80173, 80162, and 80201) provided on February 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on September 3, 2021.  You asked the Plan to waive the copayment for the EKG. You say that you never had two copayments before and you did not ask for the EKG. 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 $30 copayment for non-radiological diagnostic services, including EKG's.   You have been asked to pay $15.98, which is less than the $30 copayment for the EKG. The EKG falls within the Outpatient Diagnostic Tests 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 an electrocardiogram (EKG) provided on September 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a portable oxygen concentrator, rental, provided on September 30, 2021, by an OON provider.  You asked the Plan to pay for a portable oxygen concentrator, rental. You say that you were told by doctors that you would need oxygen support before you could leave the hospital. You also say that you had to find a way to get portable oxygen so you could return to your home in another state. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a portable oxygen concentrator, rental, provided on September 30, 2021, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ultrasound of the head and neck provided on September 28, 2021.  You asked the Plan to waive the copayment for the ultrasound. You say that you feel the amount the Plan paid was too low. 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 $160 copayment for radiological diagnostic services, not including X-rays.   You have been asked to pay $100.83, which is less than the $160 copayment for the ultrasound. The ultrasound falls within the Outpatient Diagnostic Tests 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 an ultrasound of the head and neck provided on September 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve expandable controller accessories represented by codes E2377 and E2313.  You asked the Plan to pre-approve codes E2377 and E2313. You say that the records provided support the need for the items which remain in dispute. The Plan denied your request. The Plan says the enrollee is not noted to have 3/5 upper extremity strength and is stated to feed independently. The Plan says that the enrollee has adequate upper extremity to operate switch on multiple power functions.  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 codes E2377 and E2313. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items exceed the enrollee's medical need.   The enrollee does not require non-proportional input devices. The enrollee does not require a separate display, other electronic devices, or an attendant control. The enrollee's upper extremity strength and function support that the enrollee can control any power options through their own switches.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes E2377 and E2313 have not been met. Therefore, we decided that the Plan does not have to pre-approve expandable controller accessories represented by codes E2377 and E2313.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for endoscopy services provided on September 22, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the endoscopy services. You say that the doctor's office never told you that you needed a referral from your primary care physician. The Plan denied your request. The Plan says the provider is a non-contracted facility and there was no referral from the enrollee's primary care physician.  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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for endoscopy services provided on September 22, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xiidra 5% eye drops.  You asked the Plan to pre-approve Xiidra. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 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 Xiidra 5% eye drops.    Benefits for Xiidra 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 pre-approve additional routine transportation mileage (A0170).  You asked the Plan to pre-approve additional mileage. You say that you need to see your primary care doctor for cancer treatments for five weeks. You also say you do not have any assistance and cannot drive to the location. The Plan denied your request. The Plan says you are requesting an additional 7 miles for a total of 57 miles and your benefit only allows 50 miles. The Plan also says you have exceeded your benefit limit.  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 up to 100 one-way trips and each one-way trip must not exceed 50 miles of driving distance.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles are not covered. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage (A0170).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for a specialist office visit (99203) rendered on September 24, 2021.  You asked the Plan to reduce the copayment for a specialist office visit. You say that you went to an ear, nose, throat specialist to remove wax from your ears because you could not hear. You also say that they charged you a $25 copayment and several weeks later they emailed you saying that they want an extra $5. The Plan denied your request. The Plan says you were 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 $30 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted under Medicare rules).   You have been asked to pay a $30 copayment for a specialist office visit. a specialist office visit falls within the services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted under Medicare rules) 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 reduce the copayment for a specialist office visit (99203) rendered on September 24, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on September 28, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that services were rendered to the enrollee. The Plan denied your request. The Plan says the provider is an out-of-network provider with no prior authorization obtained for services.   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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on September 28, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve four (4) additional physical therapy (PT) visits (97139).  You asked the Plan to pre-approve 4 additional PT visits. You say that the requested additional PT visits are medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not meet criteria.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 4 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had prior extensive therapy for this condition. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in and is compliant in a home exercise program.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four (4) additional physical therapy (PT) visits (97139).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility
services were medically necessary at the time of the appeal. The Plan denied your request. The Plan says
Medicare coverage criteria were 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 and the reopen request. At issue is coverage for skilled nursing
facility services. Our Physician Reviewer determined that the requested services were medically
necessary. The Plan requested a reopen and noted that the discharge instructions regarding right leg care
involved cleansing the wound with saline moistened gauze, applying Aquacel AG Advantage, covering with an
"ABD" pad, and changing it three times weekly as needed.
The medical records show you were admitted to the acute care hospital on October 26, 2021, with a wound on
the right lower extremity. You had fever, tachycardia, leukocytosis, and erythema surrounding the lower
extremity wound. You were diagnosed with sepsis and improved with treatment. At the time of discharge from
the hospital, the treatment plan was for wound care every other day or three times weekly. Therefore, the Plan
is correct in this case. The documentation does not support that skilled nursing facility services with the
specialized skill, knowledge and judgment of a skilled professional nurse were required on a daily basis in a
skilled nursing facility setting. Medicare coverage criteria were 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 skilled nursing facility services have not been met. Therefore, we decided that
the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) provided by a network facility on April 7, 2021.  You asked the Plan to waive the copayment for the MRI. You say that you have been asked to pay the correct cost-sharing amount. 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). Your contract with the Plan clearly says that you must pay a $150 copayment for each Medicare-covered advanced radiology service.    You have been asked to pay a $150 copayment for the MRI. The MRI falls within "Outpatient diagnostic tests 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 magnetic resonance imaging (MRI) provided by a network facility on April 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for ultrasounds, duplex scans, doppler study, and an electroencephalogram (EEG) provided from March 15, 2021, to September 15, 2021.  You asked the Plan to waive the copayments for the ultrasounds, duplex scans, doppler study, and EEG. You say that you are on a limited income and cannot afford the charges. 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 $50 copayment for each diagnostic radiology service in an office setting or imaging center.  Your contract with the Plan also clearly says that you must pay a $50 copayment for each outpatient diagnostic procedure and test in an office setting or imaging center.  Service Copayment Ultrasound - March 15, 2021 $50 Duplex Scan - March 25, 2021 $50 Duplex Scan - April 7, 2021 $50 Duplex Scan - April 30, 2021 $50 EEG - September 3, 2021 $50 Doppler Study - September 15, 2021 $50 Total: $300  You have been asked to pay $300 for the ultrasound, duplex scans, doppler study, and EEG. The ultrasounds, duplex scans, doppler study, and EEG fall within the Outpatient Diagnostic Tests 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 copayments for ultrasounds, duplex scans, doppler study, and an electroencephalogram (EEG) provided from March 15, 2021, to September 15, 2021.