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

 We decided that the Plan does not have to pay for the office visit provided on March 10, 2020.  You asked the Plan to pay for the services provided. You say that the claim was initially sent to Medicare. The Plan denied your request. The Plan says the time limit for filing has expired.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for the services provided was not filed until September 13, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the office visit provided on March 10, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the breast ultrasound (CPT code 76642) provided to the enrollee on August 12, 2021.  You asked the Plan to pay for the breast ultrasound. You say that the claim should be paid. The Plan denied your request. The Plan says the initial denial has been upheld per the Medicare Claims Processing Manual Chapter 1 Duplicate Claims Section 120, along with the documentation submitted of the services provided on date of service August 12, 2021, which does not support that coding guidelines have been met.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  CPT code 76642 26 RT was billed twice on the same date of service under two (2) claim numbers. Two ultrasound reports were submitted with the appeal. Although consecutive Assession numbers are noted on reach report (#3526678 and #3526679), the reports are otherwise word-for-word identical, both with physician reports signed and finalized at 09:56 AM. Furthermore, both reports state, Comparison: The present examination has been compared to prior imaging studies performed at another facility on January 23, 2019, and at another facility on March 19, 2021. There is no documentation that one (1) ultrasound was compared to the other. The Plans claims processing system documents payment of benefits for CPT 76642 26 RT. Coding guidelines have not been met and the denial remains upheld. Based on this information, we decided that Medicare rules for coverage of the breast ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the breast ultrasound (CPT code 76642) provided to the enrollee on August 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on February 18, 2021.  You asked the Plan to pay for the services provided. You say that supporting medical records were provided. The Plan denied your request. The Plan says the billed services cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We looked at the file and the rules. We find that CPT codes 80157, 80159, 80162, 80173, 80177, and 80201 are not supported in the medical record. The lab services at issue are tested using a blood sample. The records do not show that a blood specimen was obtained from the enrollee. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an anti-reflective coating (D2750) and polycarbonate lenses (V2784) provided on June 4, 2021.  You asked the Plan to pay for an anti-reflective coating and polycarbonate lenses. You say that that anything that would increase the quality of the glasses should be covered. You also say that you would like the Plan to make an exception with your claim and pay the amount that was paid for your glasses. The Plan denied your request. The Plan says the services requested are not covered by your Plan.  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 contract also says that you receive a $200 allowance toward your purchase of frames. Additional lens options including, but not limited to, Deluxe, Premium or Platinum progressive lenses, blended bifocal, Hi Index, tinting, scratch coating, UV or anti-reflective coating, and polycarbonate are not covered.  We looked at the file and the Plan's rules. The EOC confirms that anti-reflective coating and polycarbonate lenses are not a covered service with your Plan. Based on this information, we decided that the Plan's rules for coverage of anti-reflective coating and polycarbonate lenses have not been met. Therefore, we decided that the Plan does not have to pay for an anti-reflective coating (D2750) and polycarbonate lenses (V2784) provided on June 4, 2021.   Your complaint about the Plan's vision eyewear coverage 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reimburse the cost-sharing for the pembrolizumab injections (J9271) and chemotherapy infusions (96413) provided from December 1, 2020, through December 22, 2020  You asked the Plan to reimburse the cost-sharing for the pembrolizumab injections and chemotherapy infusions. You say that the cost-sharing should be reimbursed as you met your maximum out-of-pocket before the services were rendered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 20% coinsurance for Medicare Part B Prescription Drugs, specifically for each Medicare-covered chemotherapy drug and the administration of that drug.   You have been asked to pay a total of $2741.43 for the pembrolizumab injections and chemotherapy infusions.   Service Allowed Amount Standard Cost Member Liability Chemotherapy Infusion $291.54 20% $58.31 Chemotherapy Infusion $291.54 20% $58.31 Pembrolizumab Injection $10,169.20 20% $2,033.84 Pembrolizumab Injection $10,169.20 20% $590.97-Met Max OOP TOTAL:   $2741.43  The pembrolizumab injections and chemotherapy infusions fall within the "Medicare Part B Prescription Drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reimburse the cost-sharing for the pembrolizumab injections (J9271) and chemotherapy infusions (96413) provided from December 1, 2020, through December 22, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copays for the evaluation and management services provided from August 26, 2021, to August 27, 2021.  You asked the Plan to waive the copays for the services provided. You say that you were being charged as an outpatient for inpatient services. The Plan denied your request. The Plan says the benefits 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 $35 copay per specialist visit.   We looked at the file and the rules. The file shows that you received 3 visits by specialists on the dates of service at issue. The records show that you were under observation and not receiving inpatient care. You have been asked to pay a $35 copay for each specialist visit. The services fall within the physician services 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 copays for the evaluation and management services provided from August 26, 2021, to August 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health aide services, 2 hours per day, 7 days per week, and skilled nursing services, 6 additional visits per week for 9 weeks.  You asked the Plan to pre-approve 7 home health aide visits and 6 additional skilled nursing visits. You say that you really need help because you had surgery. The Plan denied your request. The Plan says the requested services are not medically necessary.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 7 home health aide visits and 6 additional skilled nursing visits. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the provided documentation does not indicate that you are homebound, given your ability to visit out-of-state family on a monthly basis. The reviewer found that you do not have documented, daily, skilled nursing needs. The reviewer found that there is no evidence that home health aide services are required to assist in the treatment of an illness or injury. Therefore, the reviewer found that the requested home health services are not medically reasonable or 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 7 home health aide visits and 6 additional skilled nursing visits have not been met. Specifically, the file does not indicate that you are homebound. Therefore, we decided that the Plan does not have to pre-approve home health aide services, 2 hours per day, 7 days per week, and skilled nursing services, 6 additional visits per week for 9 weeks.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Yervoy (J9228) and Opdivo (J9299).  You asked the Plan to pre-approve Yervoy and Opdivo. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested treatment have not been met.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Yervoy and Opdivo. Our reviewer says that the requested drugs are not medically reasonable and necessary in this case. Our physician reviewer found that the requested regimen is graded as a 2B recommendation for the enrollee's condition. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-approved cancer-drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. A 2B recommendation is, by rule, not a sufficient support for the approval of a chemotherapy regimen. No literature from Medicare-approved cancer journals was submitted for review.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Yervoy and Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Yervoy (J9228) and Opdivo (J9299).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the diagnostic services provided on August 9, 2021, by an OON provider.  

You asked the Plan to pay for the diagnostic services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  

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 the diagnostic services provided on August 9, 2021, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on January 27, 2022 with atrial fibrillation and alcoholic ketoacidosis. The physical therapy note dated February 1, 2022 states he needs contact guard assist with close supervision for sit to supine. He was stable for discharge on February 2, 2022. He has no skilled nursing needs. He has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient services provided from August 27, 2021, through August 29, 2021.  You asked the Plan to pay for the inpatient services. The Plan denied your request. The Plan says prior authorization is required for this benefit.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 inpatient services provided from August 27, 2021, through August 29, 2021.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 We decided that the Plan has to pre-approve 4 physical therapy visits. We decided that the Plan does not have to pre-approve the 4 additional physical therapy visits.   You asked the Plan to pre-approve 8 physical therapy visits. The Plan says that the test scores do not show you have made progress in your function with skilled treatment. The Plan also says that skilled treatment is not needed to maintain your function.  We decided that the Plan has to pre-approve 4 physical therapy visits.   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 8 physical therapy visits. Our reviewer says that you will benefit from 4 physical therapy visits, but not 8. Our physician reviewer found the requested therapy is generally accepted as specific and effective therapy for your condition. Our reviewer also found that the records demonstrate that the unique skills of a professional therapist are required to provide treatment safely and effectively, and that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist.  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 physical therapy visits have been met. Therefore, we decided that the Plan has to pre-approve 4 physical therapy visits.   We also decided that the Plan does not have to pre-approve the 4 additional physical therapy visits.  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 8 physical therapy 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 specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.  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 4 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the 4 additional physical therapy visits.  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to pay for air ambulance transport provided on April 16, 2021.
You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your
request. The Plan says there were several facilities that were closer to the originating hospital that could have
treated the enrollee. Maximus overturned the denial stating the Plan provided insufficient bed availability
information for those facilities stated to be closer to the originating hospital at the time of transport. The Plan
requested a reopen and stated that Maximus did not apply the correct Medicare rules.
The Plan is correct in this case. 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 and only to the nearest hospital with appropriate facilities. The rules are clear that the claimant,
not the Plan, must furnish evidence that institutions closer than the end point of the air transport did not have a
bed available at the time the ambulance service was provided. There is insufficient information provided with
the claim to show the facilities nearest to the originating facility would not have been appropriate to treat the
enrollee. Based on this information, we decided that Medicare rules for coverage of this transport have not been
met. Therefore, we decided that the Plan does not have to pay for air ambulance transport provided to the
enrollee on April 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair.  You asked the Plan to pre-approve a power wheelchair. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. Specifically, the documentation does not provide any evidence of mobility problems.        This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse an additional amount for lens polarization (V2762), polycarbonate lenses (V2784) and anti-reflective coating (D2750) provided on June 10, 2021.  You asked the Plan to reimburse an additional amount for lens polarization, polycarbonate lenses and anti-reflective coating. You say that you are entitled to additional reimbursement due to the provider's 30% discount from the cost of the eyeglasses. The Plan denied your request. The Plan says you exhausted your benefit, and you are responsible for the remaining balance.  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 contract says you have a $200 allowance once per year to use towards the purchase of covered eyewear.  We looked at the file and the Plan's rules. The records show you exhausted your $200 maximum allowed benefit on June 10, 2021. The EOC confirms that you are responsible for any amount above the coverage limit. Based on this information, we decided that the Plan's rules for coverage of lens polarization, polycarbonate lenses and anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to reimburse an additional amount for lens polarization (V2762), polycarbonate lenses (V2784) and anti-reflective coating (D2750) provided on June 10, 2021.